KUALA LUMPUR – In late January, the Chinese government responded to the outbreak of a new coronavirus with one of the world’s oldest medical procedures: quarantine. By February, more than 760 million people faced a residential lockdown of some sort. Those unlucky enough to be infected might very well be isolated at an involuntary quarantine center. The good news is that these measures slowed the spread of the virus, giving the rest of China — and the world — valuable time to prepare for a likely pandemic.
The bad news is that quarantine and isolation are usually accompanied by unwelcome side effects, including depression, anxiety and post-traumatic stress. The medical professionals treating patients and managing quarantines often face mental health burdens of their own. For China, containing and treating the virus must come first. But to successfully recover, mental health care must be a part of the response. Long-term psychological effects could be among the outbreak’s most durable legacies, with consequences for the next epidemic.
Mental health is not a subject that Chinese and their government are accustomed to discussing. Sufferers and their families are often stigmatized, with negative consequences for their social and working lives. Like most developing countries, the Chinese government has historically devoted most of its health care budget (including medical education) to meeting primary-care needs.
Yet mental illness, like any illness, isn’t something that can be pretended away. Official statistics document how mental illness — especially depression and anxiety-related disorders — has been increasing for 30 years in China. A growing number of researchers have documented the mental health impacts on Chinese of violent crime and natural disasters. Although there are no good estimates on the social and financial costs of mental illness in China, they promise to be significant. Mental and substance-use disorders account for more than 10 percent of the global disease burden, and — among other issues — disrupt family life, limit academic outcomes and reduce job performance.
As far back as the SARS cases of 2002-2003, researchers and clinicians identified the outbreak as an event that could take a mental toll on medical staff and patients. A 2006 study of 549 employees of a Beijing hospital that treated SARS patients found that 10 percent exhibited symptoms of post-traumatic stress, a condition triggered by terrifying events. Symptoms can include flashbacks, nightmares and changes in mood and thinking. Staff who had worked most closely with patients had the highest incidence, and their symptoms could persist for three years (and, presumably, past the study date). Problems weren’t confined to Beijing, either. A study of 233 SARS survivors in Hong Kong found that 40 percent had “active psychiatric illness” years after the outbreak, including post-traumatic stress, depression and obsessive compulsive disorder. Health workers had more than triple the risk of others.
During SARS, thousands of patients globally — including in China — were ordered into quarantines. In Toronto, one of the most severe hot spots, researchers surveyed 129 individuals who were quarantined, shortly after their isolation ended. Post-traumatic stress was identified in 28.9 percent, and depression was found in 31.9 percent. Patients subject to quarantines during other outbreaks outside of China, including of Middle East respiratory syndrome (MERS) and Ebola, have experienced mental stresses and health burdens. For those who already have mental illness, the isolation of quarantine can make their conditions worse.
Those studies aren’t an argument for doing away with quarantines. But a failure to monitor and treat mental health in medical professionals and patients can serve to undermine a successful quarantine. Mentally distressed patients are more likely to disobey containment orders — or outright flee. There are also concerns that distressed and depressed patients may be less willing or able to reveal recent personal contacts necessary to trace, and halt, an epidemic.
And, especially in China, there are fears that distressed patients may attack medical professionals. Those same professionals are facing mental burdens that can make them less effective at their jobs, make poor judgments or — at a period of maximum demand for medical care — simply walk away.
No data has been published to suggest that any of these phenomena are happening yet. But there are good reasons to worry. In early February, the Chinese Psychology Society surveyed 18,000 citizens for anxiety related to the coronavirus outbreak; 42.6 percent registered a positive response. Hash tags and discussions related to self-care and mental illness have surged on social media.
To an extent, the government was prepared. The National Health Commission recently released guidelines for psychological care during the epidemic and relocated mental health professionals to Wuhan. The government is also supporting the establishment and operation of emergency mental-health hot lines that are reportedly busy. But no government can be prepared to manage the mental health of tens of millions of people in a pinch — and China is especially vulnerable.
It faces a chronic shortage of mental health professionals that will take years if not decades to improve, and its tight control of media and censorship only heightens anxiety among an increasingly restless population. The Chinese government can’t reverse these policies and phenomena during the crisis, even if it wanted to do so.
For now, the success of the quarantine suggests it doesn’t have to change its approach. But the persistence of mental illness due to past epidemics suggests that China will be dealing with the side effects of its approach long after the last case of COVID-19 is cured. That will be an expensive process, both financially and socially, and one that the rest of the world should monitor as carefully as China. Quarantine, for better and worse, will be a tool in the next epidemic, too.
Adam Minter is a Bloomberg columnist.