Epidemiology and Psychiatric Psychological impact of the quarantine during

Sciences
the COVID-19 pandemic on the general
cambridge.org/eps European adult population: a systematic
review of the evidence
Special Article M. Bonati , R. Campi and G. Segre
Cite this article: Bonati M, Campi R, Segre G Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario
(2022). Psychological impact of the quarantine
Negri IRCCS, 20156 Milan, Italy
during the COVID-19 pandemic on the general
European adult population: a systematic
review of the evidence. Epidemiology and Abstract
Psychiatric Sciences 31, e27, 1–19. https://
doi.org/10.1017/S2045796022000051
Aims. Due to the coronavirus disease 2019 (COVID-19) different countries implemented
quarantine measures to limit the spread of the virus. Many studies analysed the mental health
Received: 16 December 2021 consequences of restrictive confinement, some of which focused their attention on specific
Revised: 7 February 2022 populations. The general public’s mental health also requires significant attention, however.
Accepted: 15 February 2022
This study aimed to evaluate the effects of the COVID-19 quarantine on the general popula-
Key words: tion’s mental health in different European countries. Risk and protective factors associated
COVID-19 pandemic; quarantine; review; with the psychological symptoms were analysed.
mental health; general population Methods. A systematic search was conducted on four electronic databases (PubMed,
Author for correspondence:
PsycINFO, Scopus and Google Scholar). Studies published up until 20th April 2021, and fol-
M. Bonati, lowing eligibility criteria were selected for this review. One thousand three hundred thirty-five
E-mail: [email protected] (1335) studies were screened, 105 of which were included. Via network analysis, the current
study investigated the pathways that underlie possible risk factors for mental health outcomes.
Results. Anxiety, depression, distress and post-traumatic symptoms are frequently experi-
enced during the COVID-19 quarantine and are often associated with changes in sleeping
and eating habits. Some socio-demographic and COVID-19-related variables were found to
be risk factors for an individual’s wellbeing. In particular, being female, young, having a
low income, being unemployed and having COVID-19-like symptoms or chronic disorders,
were found to be the most common risk factors for mental health symptoms.
Conclusions. The COVID-19 pandemic represented an unprecedented threat to mental
health globally. In order to prevent psychological morbidity and offer support tailored to
short-, medium- and long-term negative outcomes, it is essential to identify the direct and
indirect psychosocial effects of the lockdown and quarantine measures, especially in certain
vulnerable groups. In addition to measures to reduce the curve of viral transmission, policy
makers should urgently take into consideration provisions to alleviate hazards to mental
health.

Introduction
From December 2019 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infec-
tion spread rapidly around the world, and in March 2020, the World Health Organization
(WHO) declared a global pandemic (World Health Organization, 2020).
The impact of the coronavirus disease was dramatic also because appropriate tools for diag-
nosis and therapy were not available at the time.
Quarantine has been defined as the separation and restriction of movement of people who
have potentially been exposed to a contagious disease to ascertain if they become unwell, so
reducing the risk of them infecting others (Centers for Disease Control and Prevention,
2017). Quarantine was used mainly at the local level during historic outbreaks, e.g. during
the 2014 Ebola outbreak in African villages.
© The Author(s), 2022. Published by For coronavirus disease 2019 (COVID-19), quarantine and social distancing measures were
Cambridge University Press. This is an Open effective public health tools in limiting the dissemination and outcomes of the infection
Access article, distributed under the terms of
(Tognotti, 2013). Although the severity of these restrictions has varied between and within
the Creative Commons Attribution licence
(http://creativecommons.org/licenses/by/4.0/), countries, they have had a significant impact on people’s daily life, influencing their job, leisure
which permits unrestricted re-use, distribution activities, livelihood and social relationships. Each country’s general population has experi-
and reproduction, provided the original article enced the emotional, social and economic impact of this emergency.
is properly cited. Previous studies have shown that widespread outbreaks of infectious diseases, such as
SARS, Ebola and H1N1, are associated with psychological distress and mental health symp-
toms (Bao et al., 2020; Maalouf et al., 2021; Chaundri et al., 2021). The psychiatric implica-
tions continued far beyond the outbreak: SARS survivors reported having persistent mental
health issues years afterwards (Mak et al., 2009).
2 M. Bonati et al.

A review published at the beginning of the COVID-19 pan- ‘questionnaire’) and COVID-19 (e.g. ‘COVID’, ‘corona-virus’
demic (Brooks et al., 2020) showed that quarantines could lead and ‘pandemic’).
to deleterious psychological effects, including post-traumatic For studies to be included in this review they had to be journal
stress symptoms, confusion, anger, infection fears, frustration articles, report on primary research, be published in peer-
and boredom. reviewed journals, be written in English, include participants
Several studies have investigated the mental consequences of asked to enter into quarantine outside of a hospital environment
COVID-19 on target populations such as children, students and for at least 24 h and include data on the prevalence of mental
healthcare professionals (Husky et al., 2020; Xie et al., 2020; health symptoms or psychological wellbeing, or on related factors.
Segre et al., 2021; Stocchetti et al., 2021) In particular, studies with a cross-sectional design and longitu-
While such a focus is understandable, it is also necessary to dinal studies with data collected only during the quarantine
detect relevant changes in health behaviours that may be occur- were included. Studies were excluded if they focused on particular
ring at a community level in order to better understand the subgroups of the population such as healthcare workers, students
range of psychosocial consequences of the pandemic’s contain- or people with chronic conditions, or if they did not have full-text
ment measures. availability. The present review followed the PRISMA checklist
A systematic review and meta-analysis conducted at the begin- and reporting guidance (PRISMA-P Group et al., 2015).
ning of the pandemic (Salari et al., 2020) showed that the preva- The titles and abstracts were evaluated by the authors, inde-
lence of stress, anxiety and depression symptoms among the pendently, to decide whether to include or exclude the studies.
general population was 30% (95% confidence interval (CI) Disagreements on the eligibility of a study were resolved by dis-
24.3–35.4), 32% (95% CI 28–37) and 34% (95% CI 28–41), cussion until consensus was reached. Moreover, a review of the
respectively. references of the included studies was performed. Complete refer-
Since lifestyle behaviours can affect mental wellbeing and ences were downloaded and stored using Reference Manager
health behaviours can change during the COVID-19 pandemic 2011.0.1 software (Thompson Research Soft, Carlsbad, CA, USA).
(Parletta et al., 2016; Arora and Grey, 2020), the potential benefits After the first screening, only studies conducted during the
of mandatory mass quarantine need to be weighed against the first wave of the pandemic on European countries’ general adult
possible costs, including psychological ones. population were included. In particular, those living in countries
Although the first wave of the pandemic seems far away, two located in the European continent, extending from the island
others have followed and others, albeit less intense, may occur. nation of Iceland, in the west, to the Ural Mountains of Russia,
The use of quarantine to deal with epidemics or pandemics, how- in the east, were considered.
ever, may occur again.
Although many studies (Necho et al., 2021; Prati et al., 2021;
Zhang et al., 2021) have evaluated the mental health conse-
Data analysis
quences of the current pandemic on the general population,
there has been no published systematic review focusing primarily The network analysis approach (Borsboom and Cramer, 2013)
on the broader psychological impact of COVID-19 quarantine on was used to investigate the relationship between the 20 variables
European general population samples. considered as potential risk factors for mental health outcomes
The main objective of the present study was therefore to inves- related to COVID-19 quarantine (gender, age, educational level,
tigate the effects of the COVID-19 quarantine during the first marital status, parental status, working situation, living conditions
wave (the most intense one) on mental health and lifestyle during confinement, financial situation, social support, levels of
changes of the general population in European countries. general health, being in a vulnerable group, pre-existing mental
Specifically, it aimed to analyse the socio-demographic and health disorder, working situation, changes in diet and nutrition,
COVID-19-related variables in order to identify those individuals changes in sleep, physical activity during quarantine, living in
at elevated risk for adverse mental health outcomes. Specific focus specific areas during the pandemic, symptoms of COVID-19/
was placed on pre-quarantine predictors of psychological impact Physical symptoms, contact with COVID-19 cases, coping strat-
and stressors during quarantine. egies/strategies to deal with stress). The Fruchterman–Reingold
algorithm was used (Fruchterman and Reingold, 1991), in
which a force-directed layout dissembles the graph as a system
Methods of a large quantity of nodes or vertices. Psychological distress is
seen as a network of specific risk factors (termed nodes) that
Search strategy and selection criteria
dynamically interact with, and impact, one another. The nodes
For the present review, the Preferred Reporting Items for represent the 20 variables considered and the edges represent
Systematic Review and Meta-Analysis (PRISMA) guidelines the connections between the nodes. Nodes act as mass particles
were followed. A computer-based literature search was conducted and edges behave as springs between the nodes. The degree of a
on the following databases: PubMed, PsycINFO and Scopus, node is its number of connections (how many neighbours the
including studies published from the inception of the pandemic variable has with other variables). The figure generated shows
(January 2020) until the 20th of April 2021. A manual search the most consistent associations, where thicker edges show stron-
on Google Scholar was performed to identify additional relevant ger relationships and thinner edges weaker relationships.
studies. The full list of search terms can be found in the For each node, we calculated:
Appendix (Table A1). In brief, we used a combination of terms
relating to quarantine (e.g. ‘quarantine’, ‘isolation’, ‘confinement’ • betweenness centrality, which measures all the shortest paths
and ‘lockdown’), psychological outcomes (e.g. ‘psychological’, between every pair of nodes of the network and then counts
‘mental health’, ‘depression’, ‘anxiety’, ‘insomnia’, ‘eating habits’ how many times a node is on a shortest path between two
and ‘lifestyle changes’), survey (e.g. ‘online survey’ and others,
Epidemiology and Psychiatric Sciences 3

• closeness centrality, which calculates the shortest paths between which only 11.7% of the participants presented moderate to severe
all nodes, then assigns each node a score based on its sum of depressive symptoms on the ‘Depression, Anxiety and Stress
shortest paths, Scale’ (DASS). On the contrary, the findings of a Polish study
• eigen centrality, which measures a node’s influence based on the (Bodecka et al., 2021) showed that the majority of participants
number of links it has to other nodes in the network and can displayed at least mild depressive symptoms (82.6%). Nearly
identify nodes with an influence over the whole network, not two-thirds of the Italian respondents (61.3%) experienced
just those directly connected to it. depressed mood (Di Renzo et al., 2020).
Psychological distress has been assessed with different tools:
A community detection analysis was carried out using the the majority of the included studies used the DASS stress scale.
Louvain method (Blondel et al., 2008) to extract communities Four Italian studies (Costantini and Mazzotti, 2020; Landi et al.,
and calculate modularity. It is one of the most frequently used 2020; Pakenham et al., 2020; Bonati et al., 2021) used the
methods for clustering on large networks, it is very efficient and ‘COVID-19 Peritraumatic Distress Index (CPDI)’ with positive
allows one to define communities in a hierarchical way to responses ranging from 15 to 40%. Nearly one-third of people
group together certain nodes, diminish the dimensionality of a experienced symptoms of mild to moderate and severe peritrau-
dataset and facilitate interpretability. Network analysis was per- matic distress in two studies (Costantini and Mazzotti, 2020;
formed using Gephi version 0.9.2 (Bastian et al., 2009). Pakenham et al., 2020), while lower rates (15.5% of the sample)
Methodological quality/bias risk were recorded using the were reported in another study (CPDI mean 17.95, S.D. 11.50)
Joanna Briggs Institute critical appraisal checklist for cross- (Landi et al., 2020).
sectional and cohort studies (see Appendix Tables A2 and A3). Eighteen studies focused their attention on post-traumatic
stress disorder (PTSD) symptoms. In total, 54.4% of the Italian
participants met criteria for a clinical level of stress related pro-
Results
blems and 30% of the sample had probable diagnosis of PTSD
Figure 1 presents the procedural steps adopted and the record (Panno et al., 2020). Lower scores of PTSD (5.1%) were reported
count, duplicates and final studies obtained after screening. The in a study (Favieri et al., 2021) that specifically used the
initial search yielded 1335 studies, of which 105 included relevant Post-Traumatic Stress Disorder Related to COVID-19
data and were included in this review. (COVID-19-PTSD). High levels of avoidance symptoms at the
An overview with the characteristics of the studies is presented Impact of Events Scale-Revised (IES-R) were found in two studies
in online Supplementary Tables 1 and 2. (Fiorillo et al., 2020; Jiménez et al., 2020).
All eligible studies were included in the review, regardless of Seventeen studies focused specifically on resilience and/or cop-
their quality assessment results. Of the 98 cross-sectional studies, ing strategies, i.e. the individual’s ability to cope with stress and
45 studies (46%) were of very good quality (maximum score on adapt to changes. Resilience has been associated with a lower
the JBI) and 8 (9%) were of poor quality (JBI score <5 points). risk for any mental health symptoms; the same results were
All cohort studies were of good quality. Selected studies were obtained regarding coping (Munk et al., 2020). A higher score
conducted mainly in 17 different countries (Italy: n = 39, Spain: on the positive coping strategy dimension was associated with a
n = 25, UK: n = 9 and Greece: n = 4). lower prevalence of depressive symptoms, while more support-
ive/distractive strategies were associated with an increased preva-
lence (Skapinakis et al., 2020).
The psychological impact of quarantine
Seventy-nine studies reported anxiety symptoms in the general
Pre-quarantine predictors of psychological impact
population, with a prevalence ranging from 5.5 to 70.4%. The
highest levels of anxiety were found in an Italian study (Di Several predictive factors were identified from the included
Renzo et al., 2020); these involved 70.4% of the enrolled popula- studies.
tion, 57.8% of whom with physical manifestations of anxiety Female gender is the most common risk factor associated with
(tachycardia, headache, sweating). On the contrary, three studies psychological symptoms during the COVID emergency. The risk
(Bonati et al., 2021; Budimir et al., 2021; Silva Moreira et al., of developing anxiety, depression, distress symptoms or PTSD
2021) found low percentages of anxiety symptoms (<10% of the was double in female compared to male participants
sample). (Casagrande et al., 2020; Fiorillo et al., 2020; Gualano et al.,
A comparative investigation between Spanish and Greek parti- 2020; Landi et al., 2020; Mariani et al., 2020; Mazza et al., 2020;
cipants (Papandreou et al., 2020) observed a similar prevalence of Pieh et al., 2020; Rodríguez-Rey et al., 2020; Suso-Ribera and
moderate and severe anxiety symptoms, with 12.3% in Spain and Martín-Brufau, 2020; Bonati et al., 2021; Rettie and Daniels,
13.2% in Greece. Similar rates were found also in a German study 2021). On the contrary, a Spanish study reported similar levels
(Munk et al., 2020), in which 12% of the sample met the criteria of anxiety, stress and depression (Ozamiz-Etxebarria et al.,
for the general anxiety disorder (GAD) during the lockdown, 2020). Women reported more frequent and severe sleeping pro-
compared with 2% before the pandemic. blems (such as insomnia) than men (Bacaro et al., 2020;
Depressive symptomatology and mood variables were assessed Casagrande et al., 2020; Margetić et al., 2021); they exhibited
in 74 studies and their clinical prevalence ranged from 3.2 to more PTSD or secondary traumatic stress and posttraumatic
82.6%. Sixteen studies classified the frequency and severity of growth, were less resilient and used all kinds of coping strategies
symptoms in three categories: mild, moderate and severe. The more often (Kalaitzaki, 2021).
lowest percentages of severe depressive symptoms were found in An age-related variation was analysed in different studies: the
3.2% of the Austrian sample (Budimir et al., 2021) and 9.3% of psychological impact of COVID-19 confinement seems to ameli-
the Greek sample (Fountoulakis et al., 2021). Close rates were orate as people get older. The youngest participants (<35 years
reported in the Portuguese population (Paulino et al., 2021) in old) showed higher levels of depression, anxiety, stress, insomnia
4 M. Bonati et al.

Fig. 1. Study selection.

and PTSD symptoms compared to the other age groups (Antunes et al., 2020; Haesebaert et al., 2020; Skapinakis et al., 2020;
et al., 2020; Bacaro et al., 2020; Bonsaksen et al., 2020; Suso-Ribera and Martín-Brufau, 2020; Gutiérrez-Hernández
Rodríguez-Rey et al., 2020; Paulino et al., 2021; Rettie and et al., 2021; Silva Moreira et al., 2021). The trend of the associ-
Daniels, 2021; Rossi et al., 2021). The greater vulnerability to dis- ation with education level, however, is likely also related also to
tress in young adulthood could be due to the precariousness of the the cultural context, as found in Italian results (Bonati et al.,
working activities, with consequent interruption of income, and/ 2021) v. Portuguese ones (Paulino et al., 2021).
or the interruption of the initial phase of development of one’s Moreover, having a partner also predicted greater wellbeing
professional activity, and/or the presence of children, with result- (Haesebaert et al., 2020): married participants and those cohabit-
ing age-related concerns or the forced cohabitation in a phase in ing with their partner showed significantly lower psychological
which young adults would normally leave the family of origin. impact and felt less lonely than single participants (Balsamo
Age remained positively associated with wellbeing and negatively and Carlucci, 2020; Cerbara et al., 2020; Saita et al., 2021).
associated with depression (Dawson and Golijani-Moghaddam, Although, an Italian study (Velotti et al., 2021) reported that hav-
2020): marked differences in prevalence of depression were ing a partner was associated with overeating and social network
found between 18 and 24 year (63.3%) olds and people over 65 use during the quarantine, sharing everyday life with someone
years of age (11.5%) (Pieh et al., 2021). A similar pattern, even during quarantine was a protective factor (Dawson and
if slighter, was reported for sleep problems (Gualano et al., Golijani-Moghaddam, 2020; Gualano et al., 2020).
2020; Beck et al., 2021). Results of a Spanish (Vicario-Merino, Additionally, living with children in the household was
2020) and a UK study (Neill et al., 2021) stated that symptoms revealed as a protective factor against psychological distress, anx-
of stress and depression tended to increase with an increase in iety and depressive symptoms in five different studies
age range. (Gómez-Salgado et al., 2020; Mazza et al., 2020; Rodríguez-Rey
Being more educated predicted greater wellbeing: lower educa- et al., 2020; Ellen and De Vriendt Patricia, 2021; Saita et al.,
tional status was significantly associated with higher depression, 2021). In particular, a low rate of psychological distress was
anxiety and PTSD symptoms (Benke et al., 2020; Di Crosta observed among people living with older children or adolescents
Epidemiology and Psychiatric Sciences 5

(Gómez-Salgado et al., 2020; Rodríguez-Rey et al., 2020), but inducing common mental health problems (Balanzá-Martínez
those living with children under ten had poorer wellbeing et al., 2021).
(Haesebaert et al., 2020). In total, 74% of the participants of a French study reported
The impact of confinement was more damaging for people liv- trouble sleeping, of whom females and the young had greater
ing in very poor cohabitation conditions. In particular, participants frequency and severity (Beck et al., 2021). Reduced sleep,
living in houses of more than 120 square meters showed lower psy- poor sleep quality and changes in usual sleep patterns were asso-
chological impact, stress, anxiety and depression symptoms than ciated with more negative mood and anxiety symptoms (Bacaro
those living in less than 30 square meters (odds ratio (OR) 1.98, et al., 2020; Suso-Ribera and Martín-Brufau, 2020). Adhering to
95% CI 1.19–3.30) (Ramiz et al., 2021). Moreover, people with a routine, maintaining the same weight and moderate physical
access to an outdoor space (e.g. garden, balcony) had higher well- exercise were associated with fewer negative effects, indicating
being scores (OR 1.38, 95% CI 1.00–1.89) (Ramiz et al., 2021) and that they are important protective factors (Gismero-González
better mental health (Haesebaert et al., 2020; Ellen and De Vriendt et al., 2020). Age was inversely related to dietary control,
Patricia, 2021). Both the number of cohabitants and the quality of and being female was associated with being more anxious and
the relationships must be taken into account, however, levels of disposed to eating comfort food than males (Di Renzo et al.,
psychological distress were higher and sleep quality was lower in 2020).
people living alone (Pérez et al., 2021). Increased emotional eating was predicted by higher depressive
Being affected by a pre-existing mental disorder or having a and anxiety symptoms, quality of personal relationships and qual-
pre-existing physical disease were found to be factors associated ity of life, while an increase in bingeing was predicted by higher
with worse levels of depressive and anxiety symptoms (Fiorillo stress (Cecchetto et al., 2021).
et al., 2020; Mazza et al., 2020; Pérez et al., 2021; Rettie and The respondents who maintained the same physical activity
Daniels, 2021). In particular, people in ‘vulnerable’ groups were habits had higher levels of positive emotions (energy), lower levels
significantly more anxious, and more anxious concerning their of negative emotions (fear and anxiety) and lower levels of experi-
health, compared to individuals in nonvulnerable groups (Rettie enced symptoms (headache and fatigue) (Di Corrado et al., 2020).
and Daniels, 2021). Increased duration and greater intensity of physical activity were
both associated with further reduction in the prevalence of
depression (Jacob et al., 2020; Pieh et al., 2020), in particular in
Stressors during quarantine
females, suggesting that variations in physical activity habits
Unemployed participants, who were more vulnerable to the pos- may have more influence in women’s psychological status than
sible economic crisis in the pandemic’s aftermath, presented in men’s (Maugeri et al., 2020).
higher rates of depression, anxiety and stress symptoms compared
to employed participants (Benke et al., 2020; Pieh et al., 2020;
Network analysis
Bonati et al., 2021; Paulino et al., 2021). Unemployed participants
were also at higher risk of developing sleep disorders (68%), often The connections between the 20 prevalent variables analysed
associated with some impairment of their daytime daily activities in the retrieved studies and the structure of the network
(OR 1.34; 95% 95% CI 1.02–1.70) (Casagrande et al., 2020; Beck are shown in Fig. 2a, where the diameter of the node refers
et al., 2021). Working outside the home was associated with to the degree centrality and the hue of the node refers to
higher levels of psychological distress: people working in-presence betweenness centrality (darker = higher value). The network
showed significantly higher psychological impact compared to had 330 non-zero edges out of 380 possible edges. The weights
those working remotely (Di Giuseppe et al., 2020; of the connections are presented in online Supplementary
Gómez-Salgado et al., 2020; Mazza et al., 2020; Paulino et al., Table 3.
2021), although the type of job and professional role may affect In agreement with the narrative analysis reported above, the
the relationship (Fiorenzato et al., 2021). Economic stability, strongest connection emerged between gender and age, meaning
and socioeconomic status in general, are related to depression, that these were found to be the most common risk factors for psy-
anxiety and PTSD symptoms (Di Crosta et al., 2020; Prati, chological distress during quarantine. A cluster was found
2021): participants with high monthly family income showed between age, gender, living in specific areas and working situation
lower psychological impact than those whose family income was during the pandemic. Other noteworthy associations were
lower (Nese et al., 2022; Pieh et al., 2020, 2021; Skapinakis reported between gender and working situation, age and living
et al., 2020; Pérez-Rodrigo et al., 2021). area, and working situation and living area, during the
Health became one of the primary concerns during the quarantine.
COVID-19 confinement. Symptomatic individuals expressed Figure 2b shows the results of the community detection ana-
higher psychological impact and increased levels of depression, lysis, where the colour of the node refers to the partition of the
anxiety, stress symptoms and sleep disorders; these symptoms network. All nodes related to socio-demographic characteristics
could be interpreted as potential symptoms of COVID-19 (Beck (gender, age, working situation, living condition, financial situ-
et al., 2021; Paulino et al., 2021; Vujčić et al., 2021). Patients ation and marital status) and variables related to health (symp-
with polymerase chain reaction-confirmed COVID-19 reported toms of COVID-19/physical symptoms/being infected by
greater sleep problems (52% severe) and worse levels of depressive COVID-19, pre-existing mental health disorder) formed one
and anxiety symptoms (Fiorillo et al., 2020). Having had a contact large module (node in violet). Two nodes were found outside
with a positive case in the previous 14 days showed a statistically this large module: the first comprised of changes in diet and
significant relationship with the presence of psychological distress nutrition, changes in sleep patterns and physical activity (node
(Gómez-Salgado et al., 2020). in orange); the second one (node in green) was related to coping
Home confinement affected habits and lifestyle (in terms of strategies/responses/strategies to deal with stress and social
sleep disorders, food consumption and physical activity), support.
6 M. Bonati et al.

Fig. 2. Network analysis.

Epidemiology and Psychiatric Sciences 7

Fig. 3. Centrality measures (centrality metrics are shown as standardised z-scores).

Figure 3 shows the resulting plot for centrality metrics, which Discussion
highlights the differences in connectivity of the network.
The three indices are significantly intercorrelated with each This systematic review has analysed data from different studies
other: the correlation between eigen and closeness is 0.99 ( p < that investigated the psychological impact of the quarantine on
0.01), the correlation between eigen and betweenness is 0.91 ( p the general European population during the first wave of the
< 0.01) and the correlation between closeness and betweenness SARS-CoV-2 pandemic.
is 0.95 ( p < 0.01). Similar to those of other reviews (Luo et al., 2020; Salari et al.,
Gender, age, education, marital status, living conditions, finan- 2020), the findings of the present study highlight the fact that
cial situation, working situation and living in specific areas have anxiety, depression, distress and post-traumatic symptoms were
the highest betweenness, closeness and eigen strengths, being frequently experienced during the COVID-19 quarantine and
the most central nodes, suggesting that they have the most con- were often associated with changes in sleeping and eating habits.
nections in the network. In particular, the overall effect of the pandemic has been linked
All the centrality measures indicate that the most central with worsening psychiatric symptoms. The long-term effect of
isolation variables in the network are physical activity, contact direct COVID-19 infection has, however, been associated with
with COVID-19 case/quarantine and coping strategies/ no, or mild, symptoms (Bourmistrova et al., 2022)
responses/strategies to deal with stress. Parental status, levels of These data should be interpreted with caution since different
general health, changes in sleep patterns and symptoms of studies reported a considerable heterogeneity of mental health
COVID-19/physical symptoms/being infected by COVID-19 are problems: the impact of the COVID-19 pandemic may have
the most central variables in the distribution of the three z-scored been different across different social groups and across different
centrality metrics. contexts and countries.
8 M. Bonati et al.

An increase in mental health problems was seen from pre- Concerning the assessment tools, the majority of the studies
pandemic assessments through the first phase of lockdown; dur- used validated and reliable assessment instruments in order to
ing lockdown, no uniform trend could be identified and after investigate several domains of mental health and psychological
lockdown, mental health problems decreased slightly (Richter wellbeing. Different assessment scales were used for population
et al., 2021). screening and different cut offs were employed by studies that
Similarly, another recent review (Robinson et al., 2022) used the same tests. The self-report questionnaires used in the
observed an increase in mental health symptoms among most majority of the studies were ‘the Patient Health Questionnaire’
population sub-groups and symptom types soon after the out- (PHQ), used in 29 studies, and the GAD, used in 27 studies.
break of the COVID-19 pandemic, which then decreased and Seven studies created ad hoc questionnaires (Cancello et al.,
were comparable to pre-pandemic levels by mid-2020. 2020; Cerbara et al., 2020; Di Corrado et al., 2020; Đogaš et al.,
On the contrary, a relatively small effect of lockdowns on men- 2020; Ferrucci et al., 2020; Nese et al., 2022; Izdebski and
tal health was reported (Prati and Mancini, 2021) providing evi- Mazur, 2021). It must be noted that data collected relied on self-
dence of people’s robust capacity for resilience. report measures related to psychological symptoms, and thus can-
Several issues should be kept in mind when interpreting the not be considered sufficient to formulate diagnoses of specific
findings of the current study. disorders.
Only studies written in English have been considered in the The degree to which self-reported prevalence rates effectively
present review, and this may have led to some bias, although a represent common distress is still unknown, as well as to what
study conducted in 2012 (Morrison et al., 2012) showed that little extent this distress will result in increased rates of mental disor-
evidence of bias was introduced from the exclusion of ders and need for subsequent health treatment (Richter et al.,
non-English studies. 2021).
Some of the selected studies were conducted during the initial Although the symptomatology was assessed with widely used
stages of the COVID-19 outbreak; it is therefore possible that they screening tools, scores should not be confused with a diagnosis,
underestimated the actual occurrence of traumatic stress in the which can be assessed only by mental health professionals with
population, since delayed onset of symptoms, especially PTSD additional assessment methods such as structured clinical inter-
ones, is conceivable. Moreover, data collection time for cross- views. It is important to note that the increase in psychological
sectional studies (online Supplementary material, Fig. 4) differed distress during quarantine is related to subjective perception
also because decisions concerning time and type of quarantine and that there is a lack of pre-post pandemic analyses.
differed between European countries. Another relevant aspect that should be considered is the pos-
The majority (98 out of 105) of the selected studies had a sibility of selection bias related to the use of online surveys. The
cross-sectional observational design, which does not allow one use of online surveys, and the snowball method for increasing
to establish cause and effect relationships and temporal associ- participation, limit the generalisability of the results, although
ation between variables, so these should be interpreted with cau- surveys currently represent the best methodological choice for
tion. Time-limited, cross-sectional survey data shed little light on the data collection in a short time and in a pandemic situation. The
enduring effects of quarantine, on how adaptations to quarantine convenient non-probabilistic nature of the chosen sample may
changed or evolved over time, and on what happened during not represent the countries’ general populations: use of an online
re-opening, when home-confinement restrictions began to ease. tool limits the participation of persons who do not use this type of
Only a few studies (Ozamiz-Etxebarria et al., 2020; Salfi et al., technology, penalising, for example, elderly people or those living
2020; Ausín et al., 2021; Cheval et al., 2021; O’Connor et al., 2021; in socially disadvantaged contexts. Moreover, it was not possible
Velotti et al., 2021; Zavlis et al., 2021) analysed data at different time- to assess the participation rate since the number of subjects
points during the restrictive measures, in order to investigate the psy- who received the link to the surveys was unknown.
chological impact caused by the pandemic longitudinally. A possible gender-related effect, which may not have been
Considering that previous research on the long-term effects of identified due to the small number of men who responded, should
pandemics and quarantining (Brooks et al., 2020) has shown that also be taken into consideration. More women than men partici-
not only acute mental health effects occur, but that psychological pated in the studies, coherently with previous research, reaffirm-
distress may persist long after the crisis, it is essential to prioritise ing that it is more difficult to recruit male participants
studies with longitudinal designs. (Korkeila et al., 2001; Dunn et al., 2004). Furthermore, variable
It is thus imperative to prospectively document the synergistic distribution might differ between a sample and the population
effects of multiple co-occurring risk factors, such as economic of reference for residence, age, sex, education and other character-
precarity, unemployment, isolation, uncertainty, loss, and fear, istics, and this requires that study findings be generalised with
which may increase the likelihood of mental health difficulties. caution.
It is also important to highlight the fact that the effects of stress Lastly, more than half of the studies enrolled Italian and
exposure may not manifest themselves immediately, but, in Spanish populations: 40 studies collected data from Italy and 26
some individuals, may unfold over time (Wade et al., 2020; from Spain. This represents an unbalanced interest compared
Veldhius et al., 2021). with other European countries, although the severity of
Moreover, the processes that cultivate resilience change COVID-19 in the two Mediterranean countries from the begin-
dynamically over time, and this supports the fact that the pan- ning of the pandemic can, in part, justify such a huge production.
demic requires longitudinal analyses in order to monitor individ- All the questionnaires were launched nation-wide but, at the time
ual adaptation to uncertain conditions. of data collection, the COVID-19 outbreak was more severe in
Only four studies (Szabó et al., 2020; Castellini et al., 2021; some countries and in specific regions. This may have motivated
Lorant et al., 2021; Ramiz et al., 2021) compared data collected more people living in those areas to fill in the questionnaires com-
during the pandemic’s quarantine with the level of psychological pared to residents from other regions. Moreover, COVID-19 has
status found in the general population under normal conditions. had different mortality rates worldwide, and the severity and
Epidemiology and Psychiatric Sciences 9

Fig. 4. Timing of data collection for each European country.

10 M. Bonati et al.

frequency of mental health outcomes could be related to the Overall, despite the limitation of the studies, due also to the
intensity of the viral spread. emergency pandemic situation, the results of this review suggest
that there is an immediate psychological impact of the quarantine.
Concerning the long-lasting effects, this impact may depend on
What can be done to mitigate the consequences of
each country’s strategies and duration of restrictive measures
quarantine?
taken. To mitigate the significant negative effects on emotional
The current COVID-19 health emergency has completely chan- wellbeing, the adoption of appropriate strategies by health services
ged the daily life of the population. Both the confinement scen- is fundamental, as is preparing the general population for possible
ario and the spread of the virus, as well as associated future waves of the pandemic. When applying quarantine mea-
consequences, could alter people’s cognitive and emotional state sures, policy makers should attempt to find the right balance
through perceived threat from the virus and through development between reducing the risk of infection and minimising the risk
of negative affective balance and feelings. Several individual, eco- of negative mental consequences, while also empowering well-
nomic and psychological factors have also been found to play a being, especially in vulnerable groups.
role in the development of higher levels of symptomatology. Future research, based on longitudinal analyses, should
The pandemic has highlighted the need to pay greater atten- attempt to monitor the increase in mental health symptoms
tion to gender and to the private sphere to prevent, and alleviate, over time, in particular their course after the end of the restrictive
the psychological consequences of pandemic on more vulnerable measures. It would also be important to investigate the social
groups. context-related factors that are likely to influence their relation-
Despite the limitations of the retrieved studies, justified in part ship with quarantine.
by the need to rapidly to assess the situation as a whole, our Moreover, in addition to providing a focus on the most vulner-
results highlight the importance of identifying which groups able populations, research should investigate between-country
may face more difficulties in adopting healthy behaviours (e.g. variations that result from the confluence of specific environmen-
physical activity, healthy food choices and sleep routines) and tal stressors and time and type of quarantine in that given area.
maintaining physical and psychological wellbeing. By identifying
Supplementary material. The supplementary material for this article can
vulnerable groups, intervention strategies may be more targeted,
be found at https://doi.org/10.1017/S2045796022000051
and the effectiveness of health strategies may be improved.
Maintaining regular habits during restrictive measures could Availability of data and materials. The data are available from the authors
be considered a protective factor for mental health outcomes. upon request.
Encouraging healthy food choices, regular mealtimes and the car-
rying out of physical activity at home could therefore be a useful Acknowledgements. The authors would like to acknowledge Chiara
Pandolfini for language editing and Daniela Miglio for editing.
strategy to make the population aware of the need to remain
healthy. The promotion of correct lifestyles is important for the Author contributions. G. S. wrote the first draft of the manuscript with
protection of health, but it becomes even more important during input from M.B. R.C. did the network analysis. M.B. critically revised the art-
periods of forced home confinement in reducing long-term nega- icle and reviewed the final draft of the article. All authors had full access to all
tive effects of quarantine. Suggestions on how to maintain a cor- the data in the study and had final responsibility for the decision to submit for
rect lifestyle could be provided through video or app-based publication. The authors read and approved the final manuscript. M.B. is the
supports, but also through non-digital channels (such as TV, guarantor.
newspapers, journals, posters or leaflets) in order to reach less
Conflict of interest. All authors declare that they have no competing interests.
technology-oriented people.
Given that the most effective healthcare measure for reducing
the incidence of the coronavirus pandemic was quarantine, and
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Table A1. Keywords used for searching databases
Silva Moreira P, Ferreira S, Couto B, Machado-Sousa M, Fernández M,
Raposo-Lima C, Sousa N, Picó-Pérez M and Morgado P (2021) Keywords (searched within titles, abstracts and
Protective elements of mental health status during the COVID-19 outbreak Search query general keywords)
in the Portuguese population. International Journal of Environmental
Research and Public Health 18, 1910. 1 ‘quarantine’ OR ‘isolation’ OR ‘isolate’ OR
Skapinakis P, Bellos S, Oikonomou A, Dimitriadis G, Gkikas P, Perdikari E and ‘confinement’ OR ‘Lockdown’ OR ‘home quarantine’
Mavreas V (2020) Depression and Its relationship with coping strategies and ill- OR ‘ quarantined’
ness perceptions during the COVID-19 lockdown in Greece: a cross-sectional 2 ‘COVID’ OR ‘COVID-19’ OR ‘nCoV’ OR ‘corona-virus’ OR
survey of the population. Depression Research and Treatment 2020, 1–11. ‘outbreak’ OR ‘epidemic’ OR ‘pandemic’ OR
Stocchetti N, Segre G, Zanier ER, Zanetti M, Campi R, Scarpellini F, ‘coronavirus’ OR ‘Sars-cov-2’
Clavenna A and Bonati M (2021) Burnout in intensive care unit workers
3 ‘mental health’ OR ‘mental disorders’ OR ‘mental
during the second wave of the COVID-19 pandemic: a single center cross-
illness’ OR ‘psychiatric’ OR ‘psychological’ OR
sectional Italian study. International Journal of Environmental Research and ‘psychosocial’ OR ‘mental wellbeing’ OR ‘depression’
Public Health 18, 6102. OR ‘depressive’ OR ‘sleep disorder’ OR ‘insomnia’ OR
Suso-Ribera C and Martín-Brufau R (2020) How much support is there for ‘anxiety’ OR ‘PTSD’ OR ‘distress’ OR ‘affective’ OR
the recommendations made to the general population during confinement? ‘fear’ OR ‘phobia’
A study during the first three days of the COVID-19 quarantine in Spain.
4 ‘Survey’ OR ‘questionnaire’ OR ‘online survey’ OR
International Journal of Environmental Research and Public Health 17, 4382. ‘self-report questionnaire’
Szabó C, Pukánszky J and Kemény L (2020) Psychological effects of the
COVID-19 pandemic on Hungarian adults. International Journal of Final search 1 AND 2 AND 3 AND 4 AND 4
Environmental Research and Public Health 17, 9565. query
 Epidemiology and Psychiatric Sciences
Table A2. Critical appraisal of cross-sectional studies

Johanna Were the criteria Were the study Exposure Objective, standard Outcomes
Briggs Institute for inclusion in subjects and the measured in a criteria used for Confounding Strategies to deal measured in a Appropriate
Score (Moola the sample setting described valid and measurement of the factors with confounding valid and statistical
Study et al., 2020) clearly defined? in detail? reliable way? condition? identified? factors stated? reliable way? analysis used?

Antunes et al. (2020) 6 Y Y Y Y N N Y Y

Bacaro et al. (2020) 8 Y Y Y Y Y Y Y Y
Balanzà-Martìnez et al. 8 Y Y Y Y Y Y Y Y
(2021)
Balsamo and Carlucci 7 N Y Y Y Y Y Y Y
(2020)
Bartoszek et al. (2020) 8 Y Y Y Y N N Y Y
Beck et al. (2021) 3 N Y N N N N Y Y
Benke et al. (2020) 5 N Y N N Y Y Y Y
Bodecka et al. (2021) 4 N Y Y Y N N Y N
Bonati et al. (2021) 7 N Y Y Y Y Y Y Y
Bonsaksen et al. (2020) 8 Y Y Y Y Y Y Y Y
Budimir et al. (2021) 6 N Y Y Y N Y Y Y
Cancello et al. (2020) 5 N Y N N Y Y Y Y
Carriedo et al. (2020) 7 N Y Y Y Y Y Y Y
Casagrande et al. (2020) 8 Y Y Y Y Y Y Y Y
Casali et al. (2021) 8 Y Y Y Y Y Y Y Y
Castellini et al. (2021) 8 Y Y Y Y Y Y Y Y
Cecchetto et al. (2021) 7 N Y Y Y Y Y Y Y
Cellini et al. (2021) 7 N Y Y Y Y Y Y Y
Cerami et al. (2020) 8 Y Y Y Y Y Y Y Y
Cerbara et al. (2020) 5 N Y N N Y Y Y Y
Chodkiewicz et al. 4 N Y Y Y N N Y N
(2020)
Conversano et al. (2020) 7 N Y Y Y Y Y Y Y
Coppola et al. (2021) 8 Y Y Y Y Y Y Y Y
Costantini and Mazzotti 7 N Y Y Y Y Y Y Y
(2020)
Coulthard et al. (2020) 8 Y Y Y Y Y Y Y Y
Dawson and 8 Y Y Y Y Y Y Y Y
Golijani-Moghaddam
(2020)
(Continued )

15
Table A2. (Continued.)

16
Johanna Were the criteria Were the study Exposure Objective, standard Outcomes
Briggs Institute for inclusion in subjects and the measured in a criteria used for Confounding Strategies to deal measured in a Appropriate
Score (Moola the sample setting described valid and measurement of the factors with confounding valid and statistical
Study et al., 2020) clearly defined? in detail? reliable way? condition? identified? factors stated? reliable way? analysis used?

Di Corrado et al. (2020) 2 Y Y N N N N N N

Di Crosta et al. (2020) 7 N Y Y Y Y Y Y Y
Di Giuseppe et al. (2020) 8 Y Y Y Y Y Y Y Y
Di Renzo et al. (2020) 8 Y Y Y Y Y Y Y Y
Đogaš et al. (2020) 6 Y Y Y Y N N Y Y
Ellen et al. (2021) 8 Y Y Y Y Y Y Y Y
Favieri et al., 2021 6 Y Y Y Y N N Y Y
Ferrucci et al. (2020) 5 N Y N N Y Y Y Y
Fiorenzato et al. (2021) 8 Y Y Y Y Y Y Y Y
Fiorillo et al. (2020) 7 N Y Y Y Y Y Y Y
Fountoulakis et al. 7 N Y Y Y Y Y Y Y
(2021)
Franceschini et al. 8 Y Y Y Y Y Y Y Y
(2020)
Gambin et al. (2021) 7 N Y Y Y Y Y Y Y
García-Álvarez et al. Y Y Y Y Y Y Y Y
(2020)
Gismero-González et al. 6 Y Y Y Y Y N N Y
(2021)
Gomez-Salgado et al. 8 Y Y Y Y Y Y Y Y
(2020)
Groarke et al. (2020) 8 Y Y Y Y Y Y Y Y
Gualano et al. (2020) 7 N Y Y Y Y Y Y Y
Gutiérrez-Hernández 8 Y Y Y Y Y Y Y Y
et al. (2021)
Gunther Bel et al. (2020) 8 Y Y Y Y Y Y Y Y
Haesebaert et al. (2020) 8 Y Y Y Y Y Y Y Y
Izdebski and Mazur 5 N Y N N Y Y Y Y
(2021)
Jacob et al. (2020) 8 Y Y Y Y Y Y Y Y

M. Bonati et al.
Jacques-Avino et al. 8 Y Y Y Y Y Y Y Y
(2020)
Janè-Llopis et al. (2021) 8 Y Y Y Y Y Y Y Y
Jiménez et al. (2020) 5 N Y Y Y N N Y Y
Jung et al. (2020) 4 N Y Y Y N N Y N

Epidemiology and Psychiatric Sciences

Justo-Alonso et al. 8 Y Y Y Y Y Y Y Y
(2020)
Kalaitzaki (2021) 6 Y Y Y Y N N Y Y
Kamberi et al. (2020) 4 N Y Y Y N N Y N
Karaivazoglou et al. 7 N Y Y Y Y Y Y Y
(2021)
Landi et al. (2020) 8 Y Y Y Y Y Y Y Y
Lenzo et al. (2020) 7 N Y Y Y Y Y Y Y
Lòpez-Moreno et al. 5 Y Y Y Y N N Y N
(2020)
Lopez Bueno et al. 7 Y Y Y Y Y Y N Y
(2020a)
Lopez Bueno et al. 6 N Y Y Y Y Y N Y
(2020b)
Lorant et al. (2021) 7 N Y Y Y Y Y Y Y
Margetic et al. (2021) 7 N Y Y Y Y Y Y Y
Mariani et al. (2020) 6 Y Y Y Y N N Y Y
Maugeri et al. (2020) 5 N Y Y Y N N Y Y
Mazza et al. (2020) 8 Y Y Y Y Y Y Y Y
Méndez-Giménez et al. 7 N Y Y Y Y Y Y Y
(2021)
Silva Moreira et al. 8 Y Y Y Y Y Y Y Y
(2021)
Munk et al. (2020) 5 N Y Y Y N N Y Y
Neill et al. (2021) 8 Y Y Y Y Y Y Y Y
Nese et al. (2022) 3 N Y N N N N Y Y
Odriozola-Gonzalez 8 Y Y Y Y Y Y Y Y
et al. (2022)
Orlandi et al. (2021) 8 Y Y Y Y Y Y Y Y
Pakenham et al. (2020) 8 Y Y Y Y Y Y Y Y
Panno et al. (2020) 8 Y Y Y Y Y Y Y Y
Papandreu et al. (2020) 8 Y Y Y Y Y Y Y Y
Paulino et al. (2021) 8 Y Y Y Y Y Y Y Y
Perez et al. (2021) 8 Y Y Y Y Y Y Y Y
Pérez-Rodrigo et al. 7 N Y Y Y Y Y Y Y
(2021)
Pieh et al. (2021) 6 N Y Y Y N Y Y Y
(Continued )

17
Table A2. (Continued.)

18
Johanna Were the criteria Were the study Exposure Objective, standard Outcomes
Briggs Institute for inclusion in subjects and the measured in a criteria used for Confounding Strategies to deal measured in a Appropriate
Score (Moola the sample setting described valid and measurement of the factors with confounding valid and statistical
Study et al., 2020) clearly defined? in detail? reliable way? condition? identified? factors stated? reliable way? analysis used?

Pieh et al. (2020) 7 N Y Y Y Y Y Y Y

Prati (2021) 7 N Y Y Y Y Y Y Y
Prete et al. (2020) 8 Y Y Y Y Y Y Y Y
Ramiz et al. (2021) 6 Y Y Y Y N N Y Y
Rania and Coppola 7 N Y Y Y Y Y Y Y
(2021)
Rettie and Daniels 8 Y Y Y Y Y Y Y Y
(2021)
Rodriguez Rey et al. 8 Y Y Y Y Y Y Y Y
(2020)
Rossi et al. (2021) 8 Y Y Y Y Y Y Y Y
Rotărescu et al. (2021) 6 Y Y Y Y N N Y Y
Saita et al. (2021) 5 Y Y Y Y N N Y N
Skapinakis et al. (2020) 5 N Y Y Y N N Y Y
Suso Ribeira and 8 Y Y Y Y Y Y Y Y
Martin-Burfau (2020)
Szabó et al. (2020) 6 Y Y Y Y N N Y Y
Valiente et al. (2021) 7 N Y Y Y Y Y Y Y
Vicario-Merino (2020) 4 N Y Y Y N N Y N/A
Vujčić et al. (2021) 8 Y Y Y Y Y Y Y Y
León-Zarceño et al. 5 N Y Y Y N N Y Y
(2021)

M. Bonati et al.
 Epidemiology and Psychiatric Sciences
Table A3. Critical appraisal of cohort studies

Was
Was the follow-up
follow-up complete,
time and if not,
Johanna Were the Were the Objective, reported were the
Briggs criteria for study Exposure standard Outcomes and reasons to Were
Institute inclusion subjects measured criteria used Strategies to measured sufficient to loss to strategies to
Score in the and the in a valid for deal with in a valid Appropriate be long follow up address
(Moola sample setting and measurement Confounding confounding and statistical enough for described incomplete
et al., clearly described reliable of the factors factors reliable analysis outcomes and follow up
Study 2020) defined? in detail? way? condition? identified? stated? way? used? to occur? explored? utilised?

Ausin et al. (2021) 11 Y Y Y Y Y Y Y Y Y Y Y

Cheval et al. (2021) 11 Y Y Y Y Y Y Y Y Y Y Y
O’Connor et al. 10 N Y Y Y Y Y Y Y Y Y Y
(2021)
Ozamiz-Extebarria 8 N Y Y Y N N Y Y Y Y Y
et al. (2020)
Salfi et al. (2020) 10 N Y Y Y Y Y Y Y Y Y Y
Velotti et al. (2021) 10 N Y Y Y Y Y Y Y Y Y Y
Zavlis et al. (2021) 11 Y Y Y Y Y Y Y Y Y Y Y

19