Factors Associated with Psychological Distress and Physical Activity During the COVID-19 Pandemic

Abstract

In Morocco, as in many countries, COVID-19 spread nationwide causing a public health emergency. Strict quarantine measures implemented as a result of the pandemic have disrupted many aspects of people's lives, triggering psychological distress. A total of 256 participants were recruited through a convenience sample. Data were collected through snowball sampling, an assessment of distress symptoms using the Brief Symptoms Inventory, and an assessment of leisure-time physical activity using the Godin-Shephard Leisure-Time Physical Activity Questionnaire. Bivariate and multivariate analyses were performed. Significant changes in paranoid ideation (z = −2.45, P = .01) and interpersonal sensitivity (z = −2.01, P = .04) dimensions were noted between those who were and those who were not authorized to leave their homes during quarantine. Similarly, for physical activity, significant changes in depression (z = −2.15, P = .03), anxiety (z = −2.13, P = .03), interpersonal sensitivity (z = −1.95, P = .05), and somatization (z = −2.11, P = .03) were reported among the insufficiently active group compared with the more physically active group. From multiple regression analysis, variables correlated with general distress were type of quarantine, gender, age, education level, chronic disease, and smoking (R² = .80). With some variables, leisure-time physical activity domains appeared to be associated only with interpersonal sensitivity and somatization. Having to leave one's home during the outbreak was linked to distress, especially symptoms like suspiciousness, hostility, fearful thoughts of losing autonomy, and feelings of inadequacy, uneasiness, and discomfort during interpersonal interactions. Individuals who were moderately or sufficiently active physically reported less psychological distress.

In december 2019, an epidemic respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) appeared in Wuhan, China, expanding rapidly and affecting countries worldwide.¹ Today, the coronavirus 2019 (COVID-19) pandemic has become a global health, economic, and social crisis.^2,3

In Morocco, COVID-19 has been officially developing since March 2, 2020. Morocco analyzed COVID-19 data early on and decided to immediately adopt large-scale, drastic measures, including constraining mobility with a mandatory restrictive housing and curfew.⁴

The health state of emergency in Morocco began with varying degrees of quarantine to limit the spread of the disease from one individual to another. Such restrictive measures can reduce the incidence of contagious illness,⁵ as in the case of COVID-19, but they can also cause unprecedented disruptions to the population's health and wellbeing.⁶

Undergoing quarantine is often a difficult experience and not without risks. Disruptions to people's jobs and lives could have negative effects on their physical and mental health.⁷ However, another study found that the daily duration of home confinement was not associated with adverse mental health 4 weeks into the COVID-19 pandemic.⁸

COVID-19 continues to make headlines, with daily reports on the number of new cases and deaths. This can be a source of panic, stress, and anxiety for those who are more exposed to news reporting.⁹ One study found that satisfaction with COVID-19 updates was associated with better mental health.¹⁰

A rapid review of the evidence from during previous epidemics details the negative psychological impact of quarantine, which becomes more important when the end date is pushed back or delayed indefinitely.⁶

Ensuring psychological wellbeing should be a priority everywhere to ensure that people can effectively cope with psychologically distressing experiences.^11,12 The health benefits of physical activity on mental health and individual psychological wellbeing have been demonstrated in several studies. ^13-17

A recent scientometric analysis found that the most common research topics related to the COVID-19 pandemic include emergency care and surgery, viral pathogenesis, and global responses, but there is a lack of research on physical activity and mental health, especially related to young people.¹⁸ To our knowledge, this study is the first nationwide large-scale survey of psychological distress and its association with physical activity during the COVID-19 pandemic. For this evaluation, the Brief Symptom Inventory (BSI) was used to measure self-reported psychological distress and psychopathological symptoms. The BSI was translated and adapted linguistically and culturally.¹⁹ It shows reliable and valid psychometric properties.²⁰ In addition to the BSI, the Godin-Shephard Leisure-Time Physical Activity Questionnaire (GSLTPAQ) was used to assess physical activity in the study population.²¹

Assessing and understanding the repercussions of COVID-19 containment measures on the health and wellbeing of people in Morocco enables more informed decision making to better manage quarantine and postquarantine periods. In this article, we aim to use scores of distress and physical activity to identify the association between psychological distress and level of leisure-time physical activity, assess psychological distress among those authorized to leave home during quarantine compared with those not authorized to leave, and define which variables may be associated with psychological distress among Moroccans in quarantine during the COVID-19 pandemic.

Subjects and Methods

Study Design

A total sample of 256 participants were recruited through email, social media, and participant recommendations to participate in this study. Pool sampling included a convenience sample, and data collection was made possible through snowball sampling. Data collection started 1 week after the local and health authorities requested that people stay home to isolate and quarantine. The online link for recruiting participants was available for about 10 days.

Inclusion and Exclusion Criteria

Participants enrolled in the study were required to be 18 years of age and older, of Moroccan nationality, residents of Morocco, and in Moroccan territory at least 1 month before and during the study period. Patients with COVID-19—both confirmed and suspected cases—were excluded from the study.

Survey Instrument

The survey instrument was written in Arabic. It comprised different aspects of the participants' lives and experiences, including sociodemographic characteristic of participants, distress level, and leisure-time physical activity.

Background Information

We collected background information from each participant, including age, gender (male, female), education level (university, high school, secondary school, no qualifications), current employment (jobless, working in the liberal sector, working in the public sector), and marital status (single, married, divorced, widowed). Questions about chronic disease, drinking, and smoking were categorized as either yes or no. Finally, participants were asked about their current mobility status as determined by the Moroccan government—either they were authorized to leave home by local authorities for a compelling reason (eg, to seek goods or medication, for emergencies, to work for important jobs) or they were not authorized to leave. The degree to which participants monitored the news on COVID-19 was recorded simply as either “follow news” or “don't follow news.”

Brief Symptoms Inventory

The BSI is a self-report symptom inventory used to assess levels of psychological distress and major psychiatric symptoms.²² The inventory comprises 53 items rated on a 5-point Likert scale, covering 9 psychiatric dimensions. These dimensions include somatization, obsessive-compulsivity, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. In addition to the 9 symptoms, the Global Severity Index (GSI) refers to an individual's overall psychological distress level and can be calculated by totaling the scores of all dimensions and dividing it by the number of responses.²² The BSI has been translated into several languages including Arabic.²³ The Arabic version used in the present study has demonstrated acceptable reliability.²⁴

The Godin-Shephard Leisure-Time Physical Activity Questionnaire

The GSLTPAQ is a short self-report questionnaire used to measure leisure-time physical activity.²¹ The questionnaire asks about the number of times participants engage in mild, moderate, and strenuous leisure-time physical activity for at least 15 minutes in a typical week. The score of leisure-time physical activity is expressed in units and can be calculated by multiplying 9, 5, and 3 to weekly frequencies of strenuous, moderate, and mild activities, respectively. In summary, the following rule was adopted: 24 units or more was defined as active (substantial benefits), 14 to 23 units was defined as moderately active (some benefits), and less than 14 units was defined as insufficiently active (substantial or low benefits). Previous studies have supported the validly of this instrument.^25,26 Following World Health Organization recommendations for instrument translation, an Arabic translated version of the GSLTPAQ was used in the present study.

Statistical Analysis

The normality assumption was violated, as shown in the Shapiro Wilk test, revealing a significant value for BSI dimensions. Therefore, nonparametric tests were performed. Descriptive statistics were calculated using means, standard deviations, and frequencies. When describing variables between the 2 groups, “authorized to leave” and “not authorized to leave,” the Mann–Whitney U test was used for age, and a chi-square test (ƛ²) was performed for nominal variables. Likelihood ratios were used once the chi-square assumption was violated. The Mann–Whitney U test was used to analyze the difference between groups. When calculating the effect size (calculated by dividing the z value by the square root of N), Cohen's criteria²⁷ were adopted to interpret results: .1 was small effect, .3 was medium effect, and .5 was large effect, with significance set at 5%. Multiple regression analysis—with stepwise manual backward elimination—was carried out to determine factors associated with the 9 primary psychological symptoms and GSI among participants, using P values below .1 to retain all potentially relevant factors. GSI and BSI dimensions were qualified as outcome variables and all other different variables in the questionnaire were analyzed concurrently as potential determinants. Statistical analysis was performed by IBM SPSS for Windows version 25 (IBM Corp, Armonk, NY).

Ethical Considerations

Participation in this study was voluntary, and prior written consent was obtained. Participants were informed that they were free to refuse to participate. The online survey was self-administered, avoiding direct contact between interviewers and participants. ISP addresses were removed to ensure responses were anonymized. The ethical standards were in line with the Helsinki Declaration of 1964.

Results

The sample mean age was 33 years, with a standard deviation of 10.6 years. Men comprised 43.4% and women comprised 56.6% of the sample pool. More than half (56.3%) of participants reported being single, 38.8% were married, and 5.5% were divorced. Groups comparison based on quarantine types revealed that 20.7% were and 79.3% were not authorized to leave. No significant differences between groups were reported based on age. Sociodemographic characteristics of participants are presented in Table 1.

Table 1.

Sociodemographic Characteristics of Participants

		Quarantine Groups
Background Variable	Total Sample (n) %	Not Authorized to Leave (n = 203)	Authorized to Leave (n = 53)	U/ƛ²	Sig
Age, Mean (SD)	33 (10.6)	32.5 (10.7)	34.3 (10)	4593.000	.101
Gender
Male	(111) 43.4%	(48) 41.4%	(27) 59.9%	1.56	.211
Female	(145) 56.6%	(119) 58.6%	(26) 49.1%	1.56	.211
Marital status
Single	(144) 56.3%	(119) 58.6%	(25) 47.2%	2.84^b	.417
Married	(98) 38.3%	(73) 36%	(25) 47.2%
Divorced	(13) 5.1%	(10) 4.9%	(3) 5.7%
Widow	(1) .4%	(1) .5%	–
Education
University	(244) 95.3%	(193) 95.1%	(51) 96.2%	1.41^b	.494
High school	(9) 3.5%	(7) 3.4%	(2) 3.8%
Secondary school	(3) 1.2%	(3) 1.5%	–
Employment
Public sector	(98) 38.3%	(78) 38.4%	(20) 37.7%	12.5	.006
Private sector	(68) 26.6%	(45) 22.2%	(23) 43.4%
Still studying	(63) 24.6%	(55) 27.1%	(8) 15.1%
Jobless	(27) 10.5%	(25) 12.3%	(2) 3.8%
Chronic diseases	(25) 9.8%	(20) 9.9%	(5) 9.4%	.008	.927
Smoke	(8) 3.1%	(5) 2.5%	(3) 5.7%	1.22	.268
Use of drugs	(4) 1.6%	(2) 1%	(2) 3.8%	1.71^b	.19
Use of alcohol	(14) 5.5%	(11) 5.4%	(3) 5.7%	.005^b	.945
Monitoring news on COVID-19^a
Follows	(242) 94.5%	(196) 96.6%	(46) 86.8%	6.32^b	.012
Doesn't follow	(14) 5.5%	(7) 3.4%	(7) 13.2%	6.32^b	.012

Monitoring news on COVID-19 was recoded dichotomously, where “follows” included those following instantly, once a day, and those following 2 to 3 times a day.

Likelihood ratio test was reported based on the violation of chi-square assumption.

Abbreviations: U, Mann–Whitney U value ; ƛ², chi-square.

Psychological Distress Comparison Between Groups

Highly significant changes in paranoid ideation and interpersonal sensitivity were noted between those who were and those who were not authorized to leave their homes. In detail, a significantly higher mean was revealed for the paranoid ideation score by the group who were authorized to leave home (mean [M] = 1.30, n = 53) compared with those not authorized to leave (M = 1.02, n = 203; z = −2.46, P = .014, r = .15). Similarly, a significant difference between the means reported for interpersonal sensitivity by those who were authorized to leave home (M = 1.15, n = 53) compared with those not authorized to leave (M = .94, n = 203; z = −2.01, P = .044, r = .12). All of these differences had a small effect size. Table 2 summarizes the 9 symptoms of the BSI and GSI between those who were authorized to leave and those not authorized to leave.

Table 2.

Comparisons of Psychological Distress Between Quarantine Groups

	Quarantine Groups
Symptoms of Psychological Distress (BSI)	Not Authorized to Leave (n = 203) Mean (SD)	Authorized to Leave (n = 53) Mean (SD)	P Value	z Score	r
Global Severity Index	.97 (.56)	1.09 (.5)	.130	−1.51	.09
Anxiety	1.05 (.73)	1.10 (.62)	.394	−.85	.05
Depression	.83 (.61)	.94 (.67)	.352	−.93	.05
Interpersonal sensitivity	.94 (.73)	1.15 (.69)	.044	−2.01	.12
Hostility	.79 (.57)	.88 (.53)	.178	−1.34	.08
Obsessive-Compulsivity	1.37 (.77)	1.40 (.62)	.617	−.50	.03
Psychoticism	.80 (.68)	.93 (.61)	.099	−1.65	.10
Paranoid ideation	1.02 (.70)	1.30 (.72)	.014	−2.46	.15
Phobic anxiety	.93 (.74)	1.03 (.65)	.240	−1.18	.07
Somatization	.79 (.59)	.87 (.56)	.327	−.98	.06

Abbreviations: BSI, Brief Symptoms Inventory; SD, standard deviation.

Association Between Leisure-Time Physical Activity and Psychological Distress

Differences in psychological distress based on the level of physical activity is displayed in Table 3. Significantly higher scores for anxiety, depression, interpersonal sensitivity, and somatization were reported with the insufficiently active group compared with the physically active group. Significantly lower means were reported among the group with active physical activity for anxiety (M = .91, n = 67), depression (M = .74, n = 67), and somatization (M = .68, n = 67) domains when compared to the insufficiently active group for anxiety (M = 1.11, n = 146; z = −2.13, P = .03, r = .14), depression (M = .9, n = 146; z = −2.15, P = .03, r = .14), and somatization (M = .86, n = 146; z = −2.11, P = .03, r = .14). When comparing the moderately active group and the active group, the mean score of phobic anxiety among the moderately active group was 1.19 (n = 34), which is significantly higher (z = −2.17, P = .03, r = .21) than the active group (M = .84, n = 67). All of these differences had a small effect size.

Table 3.

Differences in Psychological Distress Based on Level of Physical Activity

Symptoms of Psychological Distress (BSI)	Insufficiently Active (n = 146) Mean (SD)	Active (n = 67) Mean (SD)	P Value	z Score	r
Global Severity Index	1.03 (.56)	.89 (.54)	.074	−1.78	.12
Anxiety	1.11 (.71)	.91 (.69)	.033	−2.13	.14
Depression	.90 (.61)	.74 (.68)	.031	−2.15	.14
Interpersonal sensitivity	1.05 (.73)	.85 (.77)	.051	−1.95	.13
Hostility	.82 (.56)	.75 (.56)	.35	−.93	.06
Obsessive-compulsivity	1.44 (.75)	1.30 (.80)	.223	−1.22	.08
Psychoticism	.84 (.71)	.80 (.64)	.863	−.17	.01
Paranoid ideation	1.13 (.75)	.96 (.68)	.137	−1.48	.10
Phobic anxiety	.95 (.74)	.84 (.68)	.342	−.95	.06
Somatization	.86 (.59)	.68 (.55)	.034	−2.11	.14

Abbreviations: BSI, Brief Symptoms Inventory; SD, standard deviation.

Identification of Different Associations

The results of the stepwise multiple linear regression analysis (by backward elimination) are displayed in Table 4. Results show that the type of quarantine, gender, age (negative direction), education level, chronic disease, and smoking were significantly correlated with the general severity index. The adjusted R² of the model was .798, which indicates that the model was well fitted for the data and valid (F = 163.69; P < .001).

Table 4.

Results of Multiple Linear Regression Analysis of BSI Symptoms

Symptoms of Psychological Distress (BSI)	Significant Predictors	Standardized Coefficient of Regression	t (P value)	R²_adj.	F (P value)
Global Severity Index	Type of quarantine	.181	2.00 (.046)	.798	163.68 (.000)
	Gender	.482	4.78 (.000)
	Age	−.210	−2.15 (.032)
	Education level	.403	2.37 (.019)
	Chronic disease	.058	1.87 (.062)
	Smoking	.111	3.77 (.000)
Anxiety	Type of quarantine	.178	1.89 (.060)	.727	132.29 (.000)
	Gender	.602	6.16 (.000)
	Age	−.181	−1.86 (.064)
	Smoking	.114	3.31 (.001)
	Monitoring news on COVID-19	.240	2.10 (.037)
Depression	Type of quarantine	.276	2.72 (.007)	.682	89.20 (.000)
	Gender	.492	4.66 (.000)
	Age	−.255	−2.43 (.015)
	Smoking	.080	1.94 (.053)
	Alcohol	.071	1.71 (.087)
	Monitoring news on COVID-19	.286	2.30 (.022)
Interpersonal sensitivity	Type of quarantine	.298	3.09 (.002)	.696	95.20 (.000)
	Gender	.483	4.66 (.000)
	Marital status	−.266	−3.02 (.003)
	Smoking	.076	2.07 (.039)
	Monitoring news on COVID-19	.357	3.06 (.002)
	GSLTPAQ domains	−.084	−1.89 (.059)
Hostility	Gender	.322	2.68 (.008)	.692	185.98 (.000)
	Education level	.484	3.99 (.000)
	Smoking	.150	4.15 (.000)
Obsessive-compulsivity	Gender	.486	4.95 (.000)	.807	259.95 (.000)
	Age	−.199	−2.17 (.030)
	Education level	.589	4.03 (.000)
	Smoking	.100	3.48 (.001)
Psychoticism	Type of quarantine	.208	1.69 (.091)	.626	83.73 (.000)
	Gender	.371	2.71 (.007)
	Age	−.262	−2.04 (.042)
	Education level	.451	1.96 (.051)
	Smoking	.115	2.85 (.005)
Paranoid ideation	Type of quarantine	.380	4.83 (.000)	.711	203.22 (.000)
	Gender	.465	5.97 (.000)
	Smoking	.101	2.87 (.004)
Phobic anxiety	Gender	.476	3.57 (.000)	.660	97.08 (.000)
	Age	−.279	−2.25 (.025)
	Education level	.771	3.72 (.000)
	Employment	−.206	−2.36 (.019)
	Smoking	.101	2.61 (.010)
Somatization	Type of quarantine	.189	2.29 (.023)	.697	114.77 (.000)
	Gender	.644	8.03 (.000)
	Chronic disease	.106	2.86 (.005)
	Smoking	.108	3.00 (.003)
	GSLTPAQ domains	−.072	−1.65 (.099)

Abbreviations: F, Fisher's test; GSLTPAQ, Godin-Shephard Leisure-Time Physical Activity Questionnaire; R²_adj., adjusted multiple determination coefficient; t, student's t-test.

Following the analysis of the regression of the different BSI subscales, only quarantine type, gender, and smoking showed a positive association with paranoid ideation, explaining 71.1% of the variability of responses. We also identified the following associations:

Anxiety is negatively associated with age and positively associated with following news on COVID-19

Depression is negatively associated with age and positively associated with consumption of alcohol and following news on COVID-19

Interpersonal sensitivity is negatively associated with marital status and GSLTPAQ domains, but positively associated with following news on COVID-19

Psychoticism is negatively associated with age and positively associated with education level

Somatization is associated with chronic disease and inversely associated with GSLTPAQ domains

Gender, education level, and smoking were common risk factors for hostility, obsessive compulsivity, and phobic anxiety. The effect was amplified by age (negative direction) for obsessive-compulsivity development and by age and employment (both on negative direction) for the manifestation of phobic anxiety. The amount of explained variance ranged between 62.6% and 80.7%.

Discussion

The present study contributes evidence on the effects of quarantine on mental health and its relation to physical activity in the Arab world. The main findings of the present study were that individuals authorized to leave home during quarantine showed significantly higher levels of interpersonal sensitivity and paranoid ideation symptoms. Physical activity during quarantine, however, showed a positive effect on psychological distress, with significant changes in anxiety, depression, and somatization. Variables predicting general distress were type of quarantine, gender, age, education level, chronic disease, and smoking. With some variables, GSLTPAQ domains appeared to be associated only with interpersonal sensitivity and somatization.

Although quarantined individuals have restricted freedom of mobility in order to contain disease transmission, nonquarantined individuals face risks in contracting a disease while conducting daily life activities. To our knowledge, few studies^28,29 have addressed the vulnerability to distress across different types of population during an outbreak. Our results, showing higher psychological distress associated with those authorized to leave quarantine to conduct daily life activities compared with those who were not authorized to leave, were not consistent with previous studies.^28-30 This inconsistency could be due to different factors; for example, it was the first time Moroccans have experienced such quarantine measures, whereas China has faced previous outbreaks of Severe Acute Respiratory Syndrome (SARS) and containment measures.³¹ Symptoms related to uneasiness and discomfort during interpersonal interactions were all higher among the group authorized to leave home; however, this could be explained by social distancing and a high degree of isolation between individuals. In addition, symptoms such as suspiciousness and fearful thoughts of losing autonomy were all present among the group authorized to leave home, which could be explained by the growing number of suspected, confirmed, and fatal cases that provoke public worry about becoming ill and spreading the illness to their loved ones.

Typical psychological responses following a biological attack include panic, fear of contagion, paranoia, and social isolation.³² Individuals who are authorized to leave their homes are more at risk of contracting the virus; accordingly, this group exhibited interpersonal sensitivity and paranoid ideation, which could be due to uncertainties related to the pandemic. In a recent study, Tian and colleagues reported similar results among ordinary Chinese citizens during a level 1 emergency response to COVID-19, where it was found that interpersonal sensitivity was among the primary psychological symptoms.³³ Participants in that study reported feeling uncomfortable eating in public places and feeling vulnerable and uncomfortable when others looked at them or talked about them.³³ Such symptoms are caused by the high degree of COVID-19 infectivity and lethality, in addition to the lack of public information during the pandemic.³⁴ A previous study shows that national polls recorded significant fear and worry related to the virus.³⁵ The fears associated with this pandemic can increase stress, panic, and interpersonal sensitivity, and similarly generate transient paranoia of becoming infected and developing and transmitting the disease. Danger of contamination was also among the factors contributing to stress and anxiety associated with COVID-19.³⁶ Similarly, people on the frontlines such as nurses and medical staff suffered from fear of infection and death.^33,37

Physical Activity and Psychological Distress

It has been well established that physical activity has a protective effect on future depression³⁸ and cognitive decline.^39,40 Physical activity is associated with less suicidal ideation¹⁵ and intense periods of physical activity reduce feelings of state anxiety.⁴¹ However, to our knowledge, it has not been assessed deeply during an outbreak or among individuals in quarantine.

Our study results on active leisure-time physical activity during the COVID-19 pandemic are in line with previous study findings that insufficient physical activity is linked to higher psychological distress.⁴² Previously published studies also support the effects of training and physical activity on negative symptoms, such as depression, anxiety, sleep dysfunction, and perceived stress in different settings.^{13,14,16,17,41,43-45} Physical activity can be incorporated into cognitive behavior therapy and can improve mental health during the COVID-19 pandemic.⁴⁶ However, in a study that addressed the effect of physical activity during an outbreak, people who exercised more during the outbreak appeared to lack a healthy lifestyle, which was inconsistent with the results in the present study.⁷

All Variables and Psychological Distress

According to regression analysis, the type of quarantine (authorized or not authorized to leave home) showed a strong correlation with most BSI dimensions, taking into account the other variables studied. Quantitative and qualitative studies found the quarantining experience to be predictive of subsequent types of psychological distress such as emotional disturbance,⁴⁷ depression,⁴⁸ stress,⁴⁹ anger,⁵⁰ grief,⁵¹ numbness,⁵² and anxiety-induced insomnia.^49,53

Based on correlation analyses, the following variables were evaluated to determine their contribution to increased BSI domains: gender (female), age (decreasing), education level (high qualifications), chronic disease (presence), and smoking (consummation).

In a Canadian study, it was suggested that demographic factors such as marital status, age, education, living with other adults, and having children were not associated with psychological outcomes and depressive symptoms during the SARS outbreak and quarantine.⁴⁸ However, these results were not consistent. A Chinese study found that the COVID-19 Peritraumatic Distress Index—to evaluate the frequency of anxiety, depression, specific phobias, cognitive change, avoidance and compulsive behavior, physical symptoms, and loss of social functioning—was associated with gender, age, level of education, employment, and region. Regarding gender, female participants showed significantly higher psychological distress than their male counterparts.⁵⁴ Thus, it is in accordance with results from previous research that women are much more vulnerable to stress and more likely to develop posttraumatic stress disorder.⁵⁵ Higher scores among the young adult group seem to confirm findings from previous research where young people tend to obtain a large amount of information from social media that can easily trigger stress.^54,56

People with higher education tended to have more distress, probably because of high self-awareness of their health.⁵⁷ Level of education may affect the public's ability to understand warnings fully in the context of respect for quarantine.⁵

Having a chronic disease predicted higher perception of body dysfunction such as complaints related to cardiovascular and respiratory systems and general distress. In China, the severity of COVID-19 was negatively associated with life satisfaction only for people with chronic medical issues.⁷ We also observed relationships between those who follow the news on COVID-19 and some BSI dimension scores. In 2015, a meta-analysis of 24 observational studies concluded that television viewing and computer or internet use were associated with the risk of depression.⁵⁸ Modern-day media depictions may make quarantine more anxiety-provoking for the public.⁵

Studies have suggested a relationship between intolerance of uncertainty and depression,^59,60 in addition to anxiety.^61-63 Adults with a tendency to use negative repetitive thought process may be at higher risk to develop psychological symptoms.⁶⁴

Confinement can also exacerbate preexisting personality traits. Telework can lead to unlimited work in a context where psychological demands are increasing.⁶⁵ During a quarantine social connectedness can cause worry about exposing other household members to an illness.⁵ The most vulnerable workers will experience stress related to financial insecurity, which in itself is a risk factor for suicide.⁶⁵

Previous studies have reported a range of psychiatric morbidities, including persistent depression, anxiety, panic attacks, psychomotor excitement, psychotic symptoms, delirium, and even suicidality in the early phase of the SARS outbreak.^66,67 One particular case was observed in India at the start of the COVID-19 crisis in which a 50-year-old man committed suicide due to his fear and panic that he had acquired the disease. However, it was discovered that he had in fact contracted an unrelated viral illness. He had been fixated on videos where Chinese COVID-19 victims were shown to collapse in public and suspected patients were forced into healthcare facilities for quarantine against their will.^68,69

This study does have limitations. Snowball sampling techniques cannot guarantee representativeness of a sample of the general population, and therefore generalizability of the results should be taken by caution. Similarly, the long-term effects of psychological distress could not be assessed due to the observational design of the study.

Conclusion

It is crucial for the public to understand the rationale behind quarantine and the psychological symptoms related to it. This would, in turn, enable them to make better informed decisions about quarantine measures during an outbreak and more effectively cope with changes during quarantine—such as integrating physical activity into their lives. This information would also help clinicians to target and treat related pathologies. Such strategies will be necessary to manage life during and after an outbreak, in the absence of a vaccine, while the risk of contagion remains and people need to leave their homes.

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