Psychological impact of social isolation on the comorbid patient: on the subject of the COVID-19 pandemic

Dear Editor,

The 2019 coronavirus disease (COVID-19) caused by the new coronavirus SARS-CoV-2 has managed to spread to most of the countries of the world unexpectedly, and has generated high rates of morbidity and mortality. Thus, in a short time it has disrupted most areas of people's daily life and has overwhelmed all health systems, the economy and all activities.

In response to the rapid spread of SARS-CoV-2, the governments of many countries, following the recommendations of the World Health Organization (WHO), have chosen to implement various public health measures such as quarantine and social isolation, which are proving effective in stopping the spread of the virus. However, these have impacted in one way or another on people's mental health.¹ To date, epidemiological data on mental health problems have not been available. Faced with this scenario, we bring up this important issue, which not only mental health professionals should consider, but also health personnel in general.²

Quarantine is defined as the restriction of the movement of people who have been potentially exposed to an infectious disease, to determine if they feel ill, which reduces the risk of them infecting other individuals. This definition differs from the term 'isolation', which refers to separating people who are already diagnosed with the disease from those who are not sick. However, the two terms are often used interchangeably, especially in communication with the public.³

In a recent review, Brooks et al.³ exposed the psychological impact of quarantine on some epidemics that have hit humanity so far in the 21st century (SARS-CoV, MERS-CoV, A/H1N1 flu and Ebola), noting that this measure has had a negative effect on people's mental health. The authors described a higher prevalence of mental symptoms, such as distress, anxiety, sadness, low self-esteem, anger, rage, isolation, low mood and insomnia, and the appearance of disorders such as depression, anxiety, obsessive-compulsive disorder, post-traumatic stress and suicide, among others.³

These mental consequences are the result of the stressors associated with quarantine and can be extrapolated to the context of the current COVID-19 pandemic. Among the stressors are the long duration of the quarantine, frustration, boredom, loneliness, fear of contracting the disease or infecting someone else, lack of information, financial losses, stigma of discrimination, financial uncertainty, or the processing of grief for a family member without culturally learned rituals for watching over them and saying last goodbyes, among others.^1,3 These factors are manifested depending on the condition of the mindset and the susceptibility of each individual.⁴

In the midst of the current pandemic, one population group that has been most affected is that of patients suffering from multiple comorbidities, pre-existing mental illnesses, addiction problems or chronic conditions such as high blood pressure, diabetes mellitus, kidney disease, asthma or COPD, among others. These patients have been shown to have worse outcomes and are therefore considered a population at risk for SARS-CoV-2 infection.¹ This new disease has also impacted on the mental health of these individuals. It is worth mentioning that these patients already have a certain susceptibility to suffer from mental disorders due to their underlying conditions.⁵ This fact, together with the psychological burden or emotional stress represented by the social isolation secondary to the COVID-19 pandemic, makes them a potentially vulnerable population group, so it is highly probable that such severe restrictions will lead this group to a loss of mental and physical functions.¹

Emotional stress brings with it neurobiological consequences that are capable of increasing the probability of exacerbating concomitant diseases, and meeting criteria for a mental disorder, especially anxiety, depression, sleep disorders and acute stress. Moreover, exaggerated concern for health can occur with different intensities, with generally erroneous and catastrophic interpretations of bodily sensations, which are secondary to the preventive lockdown resulting from the pandemic and which are usually not known by clinicians.^3,5

In this way, strategies must be generated that manage to maintain a healthy emotional stability in these patients, such as providing them with correct, truthful and highly reliable information such as that of the WHO, correcting erroneous information, helping to reduce lengthy exposure to the media and social networks with little valuable information, and recommending only reliable media.^2,3,6 In addition, it is important to identify and normalise stress reactions, teach them to recognise their own reactions and early management of these, and discuss strategies to reduce stress and anxiety, with healthy lifestyles that are within their reach and those of their companions or caregivers. Among other things, these include an explanation of preventive measures, having a 6−8 hour restful sleep, maintaining good eating habits with healthy nutrients (fruit, vegetables, little flour, low calorie foods and plenty of water), systematically exercising at least 30−60 min twice a week at home, speaking about their concerns, and staying connected with their family, friends and loved ones through social media, the phone or video calls, as this is comforting. It must be ensured that all patients have enough medication so that they do not interrupt their treatments, to avoid relapses. Furthermore, the use of information and communication technologies (ICT) should be encouraged, so that, through telemedicine or telepsychology, it is possible to contribute to the monitoring of patients, and also to the performance of cognitive behavioural therapy (CBT), accompanied by relaxation techniques of any kind (yoga or mindfulness, among others) and recreational activities in order to achieve emotional homeostasis, and thus suppress the possibility that negative and distorted thoughts arise in the present moment as a result of the underlying illnesses of these patients, which are an additional predictive factor of episodes of stress and other mental disorders.^2,3,5,6

As discussed in this document, the rapid transmission of SARS-CoV-2 and quarantine measures could exacerbate the risk of mental health problems in comorbid patients and worsen their psychiatric symptoms (if any), impairing the daily functioning and cognition of these patients. For this reason, we would like to urge that treating physicians, while keeping in mind the physical health of their patients, also bear in mind their mental health, since the body-mind binomial is the fundamental part of every human being. It is also essential that physicians work together with psychologists in the approach and instruction of these patients, agreeing on when to refer them to a psychiatrist. Knowing the importance of mental health in this population group, it is expected that a well-established relationship between doctor and psychologist can have a positive impact on the prognosis of patients and contribute to improving current statistics.

Conflicts of interest

None.