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The unintended consequences of social distancing

EMS systems may experience and respond to behavioral health, substance abuse and domestic violence situations as social isolation impacts public health


In addition to the physical effects of coronavirus, there will be additional pressures that impact our EMS system.

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As the number of global COVID-19 cases has increased exponentially, the United States is working to “flatten the curve.” State-mandated stay-at-home orders, which are essential to helping slow the spread of coronavirus, come with unintended side effects for EMS.

Ramifications result from the separation of family and friends, feelings of uncertainty, fear and even boredom, all of which can have a negative psychological impact on citizens. In addition to the physical effects of coronavirus, there will be additional pressures that impact our EMS system.

With so many people staying at home, how will this impact EMS calls?

1. Worsening mental health

Although we are fortunate stay-at-home orders are rare, this means there is a lack of research into the complexity of social isolation on mental health. A recent systematic review published in “The Lancet” looked at cases of quarantine during disease outbreaks such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome-related coronavirus (MERS), swine influenza virus (H1N1 or swine flu) and Ebola. The most frequent negative psychological effects were post-traumatic stress symptoms, confusion and anxiety [2].

“Mental Health America” reports that one in five Americans already have a mental health condition and one in two are at risk for developing one [3]. Physical distancing, changes in life plans, and a loss of routine have led to significant stress and anxiety. The stress brought on by longer periods of isolation, infection fears, frustration, boredom and financial loss can be overwhelming.

Furthermore, micro-stressors, from worrying about not being able to get a haircut to wondering when one can return to consumer shopping can accumulate and cause even more stress. People with nosophobia may refuse to leave their home, preventing them from filling essential prescriptions or exercising, needed for stress management for many people.

The loss of face-to-face mental health appointments can have disastrous consequences for some patients. Mental health providers have temporarily resorted to telehealth and are attempting to provide empathetic care to the most vulnerable patients via telecommunication.

2. Rise in substance use

A 2017 study in the “International Journal on Drug Policy” found that unemployment and the associated financial stress increases the risk of substance abuse [4]. The Substance Abuse and Mental Health Administration found that employees in certain industries, including the accommodations and food services sector, are more likely to abuse alcohol and drugs, as a group [5]. The food and hospitality industries face continued closures and loss of business, resulting in many employees being laid off and facing financial strain.

Social isolation, lack of human contact and boredom are all additional recognized risk factors for substance abuse. To make matters worse, community support programs for people rehabilitating from substance use are currently closed, further jeopardizing sobriety.

3. Spike in domestic violence

According to the National Coalition Against Domestic Violence, one in four women and one in seven men have been victims of severe physical violence by an intimate partner [6]. Several studies have found interpersonal violence increases during natural disasters or other extreme events [7]. During these uncertain times, mandatory shelter-in-place orders force some victims to stay in their home with their abusers.

With the added stress on relationships resulting from unemployment and financial strain, local domestic violence response lines across the U.S. have seen a significant increase in calls over the past several weeks [8]. Family shelters were already at capacity and voluntary advocacy groups and support programs have been suspended, making it very difficult for abuse victims to find help. Travel restrictions may also prevent victims from being able to escape their abuser. The following are some signs/patterns seen in domestic violence during these times [9]:

  • Abusive partners may withhold necessary items, such as hand sanitizer or disinfectants
  • Abusive partners may share misinformation about the pandemic to control or frighten survivors or even prevent them from seeking appropriate medical attention if they have symptoms
  • Abusive partners may withhold insurance cards, threaten to cancel insurance or prevent survivors from seeking medical attention if they need it
  • With a lockdown order in place, an abusive partner may feel more justified and escalate their isolation tactics

4. Increased mortality rates due to isolation

A meta-analysis from Brigham Young University in 2015 followed 3.4 million people over an average of 7 years. They found that the likelihood of dying increased by 26% for people who reported feeling lonely, 29% for participants who were socially isolated and 32% for those who lived alone [10]. The National Academics of Sciences, Engineering and Medicine reported that 25% of Americans over the age of 65 are socially isolated and 43% feel lonely [11]. These social distancing guidelines may prevent families from visiting their elderly loved ones or even checking in on at-risk family members.

5. Overutilization of the EMS system

Patients who frequent the EMS system are known to have high rates of social loneliness and financial strain [12]. Some also face food insecurity/shortage and an inability to pay their bills [12]. Many may have difficulties with daily activities and self-care. With the social distancing guidelines and shelter-in-place orders, this at-risk group will face increased loneliness, possible added financial strain and an inability to cope. All of this will result in an inability to perform routine daily living activities without assistance.

Read next: Self-care is critical for managing stress levels in EMTs and paramedics responding to COVID-19


  1. Mervosh S, Lu D. See Which States and Cities Have Told Residents to Stay at Home. The New York Times.
  2. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet.
  3. NAMI.
  4. Nagelhout GE, Hummel K, Goeij MCMde, Vries Hde, Kaner E, Lemmens P. How economic recessions and unemployment affect illegal drug use: A systematic realist literature review. International Journal of Drug Policy.
  5. Substance Use and Substance Use Disorder by Industry. CBHSQ Data.
  6. NCADV: National Coalition Against Domestic Violence. The Nation’s Leading Grassroots Voice on Domestic Violence.
  7. Sera Gearhart, Maria Perez-Patron, Tracy Anne Hammond, Daniel W. Goldberg, Andrew Klein, and Jennifer A. Horney.Violence and Gender.Jun 2018.87-92.
  8. Godin M. How Coronavirus Is Affecting Victims of Domestic Violence. Time.
  9. Staying Safe During COVID-19. The National Domestic Violence Hotline.
  10. Holt-Lunstad J, Smith TB, Layton JB. Social Relationships and Mortality Risk: A Meta-analytic Review. PLOS Medicine.
  11. The National Academies of Sciences, Engineering, and Medicine.
  12. Agarwal G, Lee J, McLeod B, et al. Social factors in frequent callers: a description of isolation, poverty and quality of life in those calling emergency medical services frequently. BMC public health.

Nick Thomson, BS, is a third-year medical student at the University of Washington School of Medicine. His interests are in emergency medicine, ultrasound, global health and prehospital care. He has been honored with the University of Washington School of Medicine Service Learning Award, serves as a medical student ambassador and is the student coordinator for the Marie Blanchard Friendship Clinic. Additionally, he worked with Seattle Medic One and King County Public Health Department in Seattle, Washington developing an algorithm using EMS data to track opioid overdoses.