Learning from previous lockdown measures and minimising harmful biopsychosocial consequences as they end: A systematic review

Background Infectious outbreaks, most recently coronavirus disease 2019 (COVID-19), have required pervasive public health strategies, termed lockdown measures, including quarantine, social distancing, and closure of workplaces and educational establishments. Although evidence analysing immediate effects is expanding, repercussions following lockdown measures remain poorly understood. This systematic review aims to analyse biopsychosocial consequences after lockdown measures end according to short, medium, and long-term impacts. Methods PubMed, Ovid MEDLINE, Embase, PsycInfo, Web of Science, and Scopus databases were searched from inception to January 12, 2021. Reference lists were manually reviewed. Eligible studies analysed biopsychosocial functioning after lockdown measures secondary to recent infectious outbreaks ended. Lockdown measures were defined as quarantine, isolation, workplace or educational closures, social or physical distancing, and national or local closure of public institutions deemed non-essential. Studies exclusively researching outcomes during lockdown measures, examined infectious participants, or analysed lockdown measures not pertaining to an infectious outbreak were excluded. Two independent reviewers extracted data and assessed bias with a third resolving discrepancies. Data was extracted from published reports with further information requested from authors where necessary. The mixed methods appraisal tool assessed study quality, languages were restricted to English, German, Italian, and French and narrative synthesis was applied. Results Of 5149 identified studies, 40 were eligible for inclusion. Psychological distress, economic repercussions, social, biological, and behavioural ramifications were observed. Short to medium-term effects comprised reactions relating to early trauma processing whereas medium to long-term repercussions manifested in maladaptive behaviours and mental health deterioration. Increased alcohol intake, stigmatisation, and economic effects were also identified consequences. High-risk groups included health care workers, children, elderly, inpatients, those with pre-existing psychiatric diagnoses, and socially isolated individuals. Conclusions Supporting vulnerable groups and offering education, workplace modifications, financial, and social assistance may mitigate negative repercussions. Establishing a rapid and comprehensive evidence base appraising the efficacy of such interventions and identifying areas for development is essential. This review was limited by study heterogeneity and lack of randomisation in available literature. Given the unprecedented nature and progression of COVID-19, the relevance of previous outcomes remains uncertain. Protocol registration PROSPERO registration CRD42020181134


Study selection results
Identify the number of studies screened and provide reasons for study exclusion (e.g. for comprehensive searching, provide numbers of studies screened and reasons for exclusion indicated in a figure/flowchart; for iterative searching describe reasons for study exclusion and inclusion based on modifications to the research question and/or contribution to theory development) 6-7 & Figure 1 10. Rationale for appraisal Describe the rationale and approach used to appraise the included studies or selected findings (e.g. assessment of conduct (validity and robustness), assessment of reporting (transparency), assessment of content and utility of the findings)

Appraisal process
Indicate whether the appraisal was conducted independently by more than one reviewer and if consensus was required 5-6

Appraisal results
Present results of the quality assessment and indicate which articles, if any, were weighted/excluded based on the assessment and give the rationale 6 & appendix 2 14. Data extraction Indicate which sections of the primary studies were analysed and how were the data extracted from the primary studies? (e.g. all text under the headings "results /conclusions" were extracted electronically and entered into a computer software) 6

Software
State the computer software used, if any 6

Number of reviewers
Identify who was involved in coding and analysis 5-6

Coding
Describe the process for coding of data (e.g. line by line coding to search for concepts) 6

Study comparison
Describe how were comparisons made within and across studies (e.g. subsequent studies were coded into preexisting concepts, and new concepts were created when deemed necessary) 6

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Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).

METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.

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Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.

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Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.

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Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.
Appendix 1 Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).

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Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.

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Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.

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Risk of bias in individual studies 12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.

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Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.

Study selection
17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.

Figure 1
Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations. Table 1 Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).

& appendix 2
Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.

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Synthesis of results 21 Present the main results of the review. If meta-analyses are done, include for each, confidence intervals and measures of consistency.

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Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15).