Health Psychology © 2009 American Psychological Association

2009, Vol. 28, No. 1, 91–100 0278-6133/09/$12.00 DOI: 10.1037/a0013674

Predictive Factors of Psychological Disorder Development During

Recovery Following SARS Outbreak

Mutsuko Mihashi Yasunao Otsubo

Kurume University School of Nursing Fukuoka University of Education

Xin Yinjuan Kaori Nagatomi, Michiko Hoshiko, and

TOTO Co., Ltd., Beijing, China Tatsuya Ishitake
Kurume University School of Medicine
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Objective: To investigate strategies for broad mass isolation during outbreaks of infectious diseases. Design:
A survey using a self-administered questionnaire was conducted on 300 printing company workers in Beijing,
China, which was under mass isolation following the 2003 SARS outbreak, in the 7– 8 months after the
isolation was lifted. Main Outcome Measures: Individuals with psychological disorders were classified on the
basis of scores on the 30-item General Health Questionnaire during the recovery period. Psychological
disorders were observed in 49 of 187 respondents (26.2%; 95% CI ⫽ 20.2, 32.7). Results: The predicting
factor with the highest correlation was income reduction, with an odds ratio of 25.0. Other items obtained were
gender, range of activities, eating restrictions, restrictions in going out, disinfection of clothing, and infection
control, with odds ratios of 3.2, 5.5, 3.9, 3.2, 0.2, and 0.1, respectively, and the contribution ratio was 87.7%.
Conclusion: Securing income is suggested to be important in future strategies.

Keywords: SARS outbreak, mass isolation, psychological disorders, recovery period, GHQ–30

The atypical pneumonia SARS (severe acute respiratory syn-
drome) was first reported in Hong Kong and Vietnam in March
2003, after which cases were reported in several other countries,
including China, Taiwan, and Canada. The number of patients,
deaths, and survivors reached 8,422, 916, and 7,442, respectively,
on August 7, 2003. On July 5, 2003, the end of the epidemic was
effectively declared when Taiwan was removed from the list of
areas with recent local transmission of SARS. Nevertheless, hu-
man beings still face the continuing threat of emerging infectious
disease epidemics, such as avian influenza, West Nile fever, and
new variants of influenza.
In Japan, one case of potential threat of SARS infection was
reported in which a Taiwanese doctor/tourist to Japan was
affected by the disease after returning to Taiwan. This incident
provided insight into developing risk-management systems for
infectious diseases in Japan, and led to investigation of various
measures, such as countering the anxiety of citizens, instituting
practical methods for disinfection, and addressing the misinfor-
Mutsuko Mihashi, Kurume University School of Nursing, Kurume City,
Japan; Yasunao Otsubo, Fukuoka University of Education, Fukuoka, Ja-
pan; Xin Yinjuam, TOTO Co., Ltd., Beijing, China; Kaori Nagatomi,
Michiko Hoshiko, and Tatsuya Ishitake, Kurume University School of
Medicine, Kurume City, Japan
We extend deep appreciation to those at the printing company and
universities in Beijing for their cooperation in this survey.
Correspondence concerning this article should be addressed to Mutsuko
Mihashi, Department of Environmental Medicine, Kurume University
School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan. E-mail:
mihashi@toq.ne.jp
mation panic (Asanuma & Onose, 2004; Kawana, 2004; Kiku-
chi, 2004; Kudo, 2004; Murata, 2004; Ohara, 2004; Okabe,
2004; Teruya, 2004; Yoshida & Sakio, 2004). Maunder et al.
(2003) examined the immediate physical, sociopsychological,
and occupational impacts on 19 true and suspected SARS
patients, who were isolated after March 13, through a retro-
spective interview survey. Brug et al. (2004) conducted a Web-
based electronic survey of 373 individuals regarding SARS-
associated risk perception, knowledge, precautions, and
information sources in SARS-free countries. Many studies in
Japan and other countries have described the effects and strat-
egies of infection prevention from the standpoints of medical
care and administration, whereas few studies have presented
results leading to the effective strategies by focusing on the
psychological aspects of the participants. Infection control mea-
sures naturally require that their utmost priority be on infection
prevention; however, they may pose a risk of compromising
human rights and physical and psychosociological aspects of
the subjects. Toward systematization of more effective quaran-
tine strategies for unpredictable future outbreaks, it is extremely
valuable to conduct surveys of subjects who have undergone the
unique experience of broad quarantine.
Facing the SARS epidemic, residents of Beijing, China, expe-
rienced an unprecedented citywide isolation, including home and
university quarantines. In this study, we investigated mid- and
long-term psychological conditions after the lifting of collective
quarantine. Through analyzing the factors affecting the psycholog-
ical conditions, we aimed to illustrate the potential of risk control
and to obtain guidelines for infection prevention strategies for
future outbreaks of infectious diseases.

91
 92 MIHASHI ET AL.
The 30-item General Health Questionnaire (GHQ–30) is em-
ployed as a measure of evaluating psychological status. Developed
by Goldberg (1972), the GHQ is a self-evaluating questionnaire
widely used around the world to screen the nonorganic and non-
psychotic psychological disorders in patients of general psycho-
matics and community residents. GHQ–30 is an abbreviated ver-
sion of the original questionnaire with 60 items, and is appreciated
as a very reliable diagnostic test in the field of psychiatry (Jiang
et al., 2003). In particular, its screening effectiveness for identify-
ing and assessing the symptoms of psychological disorder is con-
sidered extremely high. A number of previous studies have em-
ployed the GHQ–30 in examining the correlation between various
factors and psychological disorders. For example, there are reports
on congenital cardiac diseases (Cox, Lewis, Stuart, & Murphy,
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2002), angina (Rasul, Stansfeld, Hart, Gillis, & Smith, 2002),
cirrhosis (Aghanwa & Ndububa, 2002), and other physical disor-
ders (O’Connor, Cobb, & O’Connor, 2003; Rasul, Stansfeld, Hart,
Gillis, & Smith, 2004). Other studies have focused on subjective
factors, such as religion (O’Connor et al., 2003) and personality
(Persson & Ørbak, 2003), and objective factors, such as economic
conditions (Hodiamont, Rijnders, Mulder, & Furer, 2005), income
(Cheng, Chi, Boey, Ko, & Chou, 2002), and natural disaster and
trauma (Eid, Johnsen, & Saus, 2005; Johnsen, Eid, Laberg, &
Thayer, 2002; Kokai, Fujii, Shinfuku, & Edwards, 2004). Mean-
while, Li et al. (2007) reported on psychological disorders of
Chinese students in Japanese language schools by investigating
various adjustment problems arising from intercultural exposure.
Developed in conformity with the World Health Organization
(WHO) version, GHQ–30 asks questions only about everyday and
immediate topics, which allows it to serve as an instrument for
international comparative studies.
As for the impacts during quarantine, a conceptual model de-
veloped in reference to an assistance model under the cohort
isolation during a 1998 dysentery outbreak (Mihashi, 2001) was
used to guide the factors. Assuming that a worldwide epidemic of
an infectious disease is a manmade disaster, the postdisaster psy-
chological status should change over time. In this sense, it is
natural that the size of the disaster and the timing of survey
influence the mental conditions. For this reason, we examined the
impacts at the periods of recovery and isolation.
Method
Participants
Respondents consisted of 218 individuals who responded to a
survey among workers at a printing company located on the
campus of “A” University in Beijing, where the 2003 SARS
outbreak occurred, as well as the university faculty members and
their family members (n ⫽ 200) and 100 freshmen at “B” Uni-
versity in the city (nonmedicine majors). The response rate was
72.7% (218/300). Among the respondents, 187 individuals
(62.3%: 187/300) who completed the GHQ–30 were used as
effective responses.
Procedures
A questionnaire survey was created in Japanese and translated
into Chinese (simplified Chinese). A pretest was conducted on six
Chinese people living in Japan. The anonymous and self-
administered questionnaire explicitly stated the purpose and the
voluntary nature of the survey. Questionnaire forms were directly
delivered to participants who agreed to complete the forms, which
were then collected individually by mail.
Survey Period
The survey was conducted from February 23 to the middle of
March 2004. This period was approximately 7– 8 months after the
end of the 2003 worldwide SARS outbreak (hereinafter referred to
as the “recovery period”).
Ethical Considerations
This study was reviewed and approved by the Institutional
Review Board of Kurume University in Japan. There was no
authority equivalent to an external institutional review board at the
institute where the data were obtained, although every possible
ethical consideration was paid in conducting the survey. First,
prior to the survey, the purpose and the details of the survey were
mailed to the persons in charge of the facilities to obtain their
consent and cooperation. Along with the purpose of the survey, the
questionnaire clearly stated that completing the survey was on
voluntary, participants had the right to refuse cooperation, and the
survey had nothing to do with work or grade performance evalu-
ation. The survey forms were directly delivered to the facilities by
the authors. It was requested that no pressure by persons in charge
be applied with regard to distribution and collection of the forms.
Forms were individually enclosed in envelopes on distribution and
collection. If individuals had any questions or comments regarding
the survey, they were instructed to contact the authors directly.
Structure of Questionnaire Items
The questionnaire consisted of the following five categories:
respondent attributes, symptoms, restrictions in daily life, support,
and cognition. The respondent attributes category contained items
regarding age, gender, involvement in health care (experience of
work in health care sectors or study of medical subjects), occupa-
tion, and medical treatment. The symptoms category contained
items regarding fever, cough, respiratory distress, muscular pain,
headache, and diarrhea. The restrictions in daily life category
contained items regarding range of activities, controlling infection,
using the telephone, watching television, purchasing food and
clothing, bathing, smoking, eating, mask wearing, disinfecting
clothing, going out, quarantine, exercising and sports, and continu-
ing study/work. The support category contained items regarding
income reduction, medical/nursing care, and social support. The
cognition category contained knowledge of SARS, and impression
of SARS risk, which was defined as an individual’s psychological
evaluation of the possibility of SARS harming humans and ani-
mals. Despite the possibility of some information being lost, all the
variables were dichotomized because most of the responses clus-
tered around one or the other for these measures and thus the
measures were in effect dichotomous.
Finally, respondents were requested to provide two sets of
responses to the GHQ–30 (Goldberg & Hiller, 1979): one for the
time at the survey (recovery period: 7– 8 months after the out-
 PSYCHOLOGICAL DISORDERS FOLLOWING SARS OUTBREAK
break) and the other for the time of the outbreak (quarantine
period) through recollection. The Cronbach’s alpha coefficient
values for all 30 items were .868 during the quarantine and .874 at
the recovery period.
We developed 17 original questionnaire items for the risk im-
pression scale, which was tested on 60 Japanese university stu-
dents in a pilot study. A two-factor solution was employed, based
on the previous studies by Teigen, Brun, & Slobic (1988) and
Slovic (1986). In consideration of stress among subjects, four
items with large factor loadings were selected for each factor. The
contributions of Factors I and II were 37.4% and 23.0%, respec-
tively, and the cumulative contribution was 60.4%.
For Factor I, the following four “fear” factors were selected:
Level of Threat (normal– dreadful), Level of Fatality (not fatal–
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fatal), Future Influence (influence will not remain in the future–
influence will remain in the future), and Worldwide Influence
(influence is not worldwide–influence is worldwide).
For Factor II, the following four “unknown” factors were se-
lected: Scientifically Unknown (scientifically known–
scientifically unknown), Level of Recognition (not accurately
knowing the danger–accurately knowing the danger), Observabil-
ity (possible to observe–impossible to observe), and Unknown
Upon Contact (person in contact does not know–person in contact
knows). A 7-point Likert-type scale was employed for all eight
items, with higher scores indicating higher impressions. The Cron-
bach’s reliability coefficients were ␣ ⫽ .657 for the four fear
factors and ␣ ⫽ .587 for the unknown factors.
Analytical Methods
On the risk impression for infectious diseases, the cutoff point
was set at score 4, which was the border of each quadrant in both
spaces of fear and unknown factors. Scores below 4 were evalu-
ated as “weak impression,” and those above 4 were evaluated as
“strong impression.”
The GHQ–30 (Goldberg & Hiller, 1979) uses a 4-point rating
system comprising not at all, no more than, rather more than,
and much more than, and a simple traditional rating system (0,
0, 1, 1) was employed for grading. The cutoff point that
distinguished the “possibility of having nonpsychotic psycho-
logical disorders” was set between scores 6 and 7, where the
misclassification rate showed the lowest (10.8% with sensitivity
at 92 and specificity at 85) in discriminative efficiency (Daibou
& Nakano, 1987). Respondents with scores of 6 or below were
identified as healthy, whereas those with scores above 7 were
identified as having psychological disorders.
The framework for analysis was built with the following two
elements: (a) The isolation and the recovery periods were
compared using the McNemar test. The psychological impacts
on disaster victims are known to change with the course of time,
and a similar change is expected to happen when understanding
the SARS epidemic as a manmade disaster. (b) To analyze the
factors that influence GHQ–30 scores during the recovery pe-
riod, we obtained an odds ratio (OR) of psychological disorders
and the 95% confidence interval (CI) using a univariate logistic
regression model with the GHQ–30 scores as dependent vari-
ables. Next, to extract variables related to psychological disor-
ders, we performed a multivariate logistic regression analysis (for-
ward selection method: likelihood ratio) for the respondent attributes,
93
symptoms, restrictions in daily life, support, and recognition catego-
ries, and items with high contribution ratios were selected to evaluate
their ORs. In addition, because of their significant importance in the
risk control of future infectious disease outbreaks, the two risk im-
pression variables (fear and unknown impressions) were force en-
tered, and then the items extracted in each category were entered in a
forward selection procedure to perform a multivariate logistic regres-
sion analysis (likelihood ratio). SPSS 12.0 for Windows was used for
statistical analysis, and the level of significance was set at 5%.
Results
Respondent Attributes
The mean age of the respondents was 26.3 ⫾ 8.0 years. There
were 117 men, 69 women, and 1 person did not indicate his or her
gender. For the involvement in health care, 5 respondents reported
positive, 164 reported negative, and 18 gave no response. For
occupation, 96 respondents worked for the company or universi-
ties, and 91 were university students or had other occupations.
Forty-four respondents received medical treatment, 138 underwent
no medical treatment or isolation, and 5 gave no response. For
symptoms, 7 of 136 (3.8%) had fever, 7 of 185 (3.8%) had cough,
5 of 185 (2.7%) experienced respiratory distress, 4 of 185 (2.2%)
had muscular pain, 11 of 186 (5.9%) had headache, and 4 of 185
(2.2%) had diarrhea; the prevalence rates remained generally low,
ranging between 2.2% and 5.9%.
Frequency of Psychological Disorders According
to GHQ–30
Of 187 respondents, 46 (24.6%) scored above 7 on the
GHQ–30 and were thus identified as having psychological
disorders during the isolation period; 49 (26.2%) scored above
7 on the GHQ–30 during the recovery period. Comparing the
two periods, 147 respondents showed no changes, whereas 6
respondents who suffered psychological disorders during the
quarantine period experienced their symptoms subsiding during
the recovery period, and 13 respondents who showed no symp-
toms during the quarantine period developed psychological
disorders during the recovery period. With these data, no sig-
nificant differences were observed between the two groups
( p ⫽ .169). The correlation coefficient for the GHQ–30 be-
tween the periods was .78 ( p ⬍ .001), which indicated a strong
positive correlation.
Factors Related to Psychological Disorders
Factors and odds ratios. Table 1 shows the ORs and 95% CIs
of individuals with psychological disorders vis-à-vis all items in the
respondent attributes, symptoms, restrictions in daily life, support, and
cognition categories, which were obtained with a univariate logistic
regression model. The variables and ORs demonstrating a significant
correlation with individuals with psychological disorders were male
gender (OR ⫽ 3.5), company/university staff occupation (OR ⫽ 3.2),
positive for fever (OR ⫽ 7.7), positive for headache (OR ⫽ 5.5),
restricted range of activities (OR ⫽ 4.2), restricted television viewing
(OR ⫽ 3.1), restricted smoking (OR ⫽ 2.8), restricted eating (OR ⫽
2.4), not wearing a mask (OR ⫽ 2.6), restricted going out (OR ⫽ 2.7),
no continuation of schooling/working (OR ⫽ 2.5), and experienced
 94 MIHASHI ET AL.

Table 1
Correlation With Items in Each Category by Psychological Disorder During Recovery Period

Healthy Psychological
Category (GHQ ⬉ 6) disorders (GHQ ⭌ 7) OR 95% CI p

Respondent attributes
Age
⭌ 23 years old 70 (72.2) 27 (27.8) 1.0
⬍ 23 years old 68 (76.4) 21 (23.6) 0.8 0.4–1.6 .051
Gender
Female 60 (87.0) 9 (13.0) 1.0
Male 77 (65.8) 40 (34.2) 3.5 1.6–7.7 .002
Involvement in health care sector
Yes 1 (20.0) 4 (80.0) 1.0
No 122 (74.4) 42 (25.6) 0.1 0.0–0.8 .007
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Occupation
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University student 77 (84.6) 14 (15.4) 1.0

Other company staff, university staff 61 (63.5) 35 (36.5) 3.2 1.6–6.4 .001
Treatment/isolation
No 108 (78.3) 30 (21.7) 1.0
Yes 28 (63.6) 16 (36.4) 2.1 1.0–4.3 .055
Symptoms
Fever
No 135 (75.4) 44 (24.6) 1.0
Yes 2 (28.6) 5 (71.4) 7.7 1.4–40.9 .017
Cough
No 134 (75.3) 44 (24.7) 1.0
Yes 3 (42.9) 4 (57.1) 4.1 0.9–18.9 .074
Respiratory distress
No 135 (75.0) 45 (25.0) 1.0
Yes 2 (40.0) 3 (60.0) 4.5 0.8–27.8 .105
Muscular pain
No 136 (75.1) 45 (24.9) 1.0
Yes 1 (25.0) 3 (75.0) 9.1 0.9–89.4 .056
Headache
No 133 (76.0) 42 (24.0) 1.0
Yes 4 (36.4) 7 (63.6) 5.5 1.6–19.9 .009
Diarrhea
No 136 (75.1) 45 (24.9) 1.0
Yes 1 (25.0) 3 (75.0) 9.1 0.9–89.4 .059
Restrictions in daily life
Range of activities
No regulation 88 (85.4) 15 (14.6) 1.0
Regulation 47 (58.0) 34 (42.0) 4.2 2.2–8.6 .000
Infection control
No regulation 81 (73.6) 29 (26.4) 1.0
Regulation 55 (73.3) 20 (26.7) 1.0 0.5–2.0 .963
Telephone
No regulation 126 (75.9) 40 (24.1) 1.0
Regulation 12 (57.1) 9 (42.9) 2.4 0.9–6.2 .071
Television
No regulation 131 (75.7) 42 (24.3) 1.0
Regulation 7 (50.0) 7 (50.0) 3.1 1.0–9.4 .043
Foods/clothing
No regulation 89 (74.8) 30 (25.2) 1.0
Regulation 49 (72.1) 19 (27.9) 1.2 0.6–2.3 .683
Bathing
No regulation 101 (74.3) 35 (25.7) 1.0
Regulation 37 (72.5) 14 (27.5) 1.1 1.4–5.7 .812
Smoking
No regulation 109 (80.1) 27 (19.9) 1.0
Regulation 29 (59.2) 20 (40.8) 2.8 1.4–5.7 .005
Eating
No regulation 103 (79.2) 27 (20.8) 1.0
Regulation 35 (61.4) 22 (38.6) 2.4 1.2–4.7 .012
Mask wearing
Yes 117 (77.5) 34 (22.5) 1.0
No 20 (57.1) 15 (42.9) 2.6 1.2–5.6 .016
(table continues)
 PSYCHOLOGICAL DISORDERS FOLLOWING SARS OUTBREAK 95

Table 1 (continued )

Healthy Psychological
Category (GHQ ⬉ 6) disorders (GHQ ⭌ 7) OR 95% CI p

Disinfection of clothing
No 112 (73.2) 41 (26.8) 1.0
Yes 25 (75.8) 8 (24.2) 0.9 0.4–2.1 .763
Going out
No regulation 79 (82.3) 17 (17.7) 1.0
Regulation 56 (63.6) 32 (36.4) 2.7 1.4–5.3 .005
Isolation
No 125 (75.3) 41 (24.7) 1.0
Yes 12 (60.0) 8 (40.0) 2.0 0.8–5.3 .148
Exercise and sport
No regulation 115 (73.7) 41 (26.3) 1.0
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Regulation 23 (74.2) 8 (25.8) 1.0 0.4–2.4 .956

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Studies/working
Continuation 122 (76.7) 37 (23.3) 1.0
Not continue 16 (57.1) 12 (42.9) 2.5 1.1–5.7 .033
Support
Income reduction
No 123 (83.7) 24 (16.3) 1.0
Yes 13 (34.2) 25 (65.8) 9.9 4.4–21.9 .000
Medical/nursing care
Available 46 (64.8) 25 (35.2) 1.0
Not available 92 (79.3) 24 (20.7) 0.5 0.3–0.9 .030
Support
Available 55 (71.4) 22 (28.6) 1.0
Not available 83 (75.5) 27 (24.5) 0.8 0.4–1.6 .538
Cognition
Knowledge
Know 74 (73.3) 27 (26.7) 1.0
Not know 62 (73.8) 22 (26.2) 1.0 0.5–1.9 .934
Fear impression
Low 15 (65.2) 8 (34.8) 1.0
High 107 (73.8) 38 (26.2) 0.7 0.3–1.7 .394
Unknown impression
Low 116 (75.8) 37 (24.2) 1.0
High 11 (57.9) 8 (42.1) 2.3 0.9–6.1 .100

Note. GHQ ⫽ General Health Questionnaire; OR ⫽ odds ratio; CI ⫽ confidence interval.

income reduction (OR ⫽ 9.86). A factor showing a correlation op-
posite to our expectations was “not available at all” for medical/
nursing care (OR ⫽ 0.48).
Determination of predictive factors of psychological disor-
ders. Table 2 shows the variables with the highest contribu-
tion rates obtained by entering each item from the five catego-
ries as variables into the multivariate model (forward selection
method: likelihood ratio).
In respondent attributes, where four variables were entered,
the variables indicating a significant correlation were gender,
occupation, and medical treatment. The ORs of individuals with
psychological disorders for each variable were 3.8 for male
gender, 3.0 for company/university staff occupation, and 3.2 for
receivedmedical treatment, with the contribution scoring
75.7%. In symptoms, where six variables were entered, the item
fever was extracted. The OR and the contribution rate for
having fever were 7.9 and 75.7%, respectively.
In restrictions in daily life, 14 variables were entered to extract
the following variables and ORs: restricted range of activities
(OR ⫽ 5.7), restricted eating (OR ⫽ 5.0), not wearing a mask
(OR ⫽ 2.9), restricted going out (OR ⫽ 3.8), and experienced
isolation (OR ⫽ 3.9). Correlations opposite to our expectations were
observed in performed infection control, performed disinfection of
clothing, and restricted exercise and sports; ORs were 0.3, 0.1, and
0.3, respectively, with the contribution rate being 80.9%.
In support, entry of three variables extracted the item positive
in income reduction, with an OR of 9.9 and a contribution of
80.0%.
In cognition of SARS, where three variables (knowledge, fear
impression, and unknown impression) were entered, the weak
unknown impression was selected, with its OR and contribution
being 2.6 and 72.4%, respectively.
Furthermore, to select predictive factors for risk control in
outbreaks of infectious diseases, we force entered the fear
impression and unknown impression variables, and then we
entered the variables with a significant correlation with indi-
viduals having psychological disorders in the multivariate
model into the multivariate model (forward selection method:
likelihood ratio). The results are shown in Table 3.
The ORs for weak fear impression and weak unknown impres-
sion were 2.2 and 3.8, respectively, although no significant corre-
lations were identified. The following seven variables were ulti-
mately selected as predictive factors: gender, range of activities,
eating restrictions, restrictions in going out, income reduction,
 96 MIHASHI ET AL.

Table 2
Category Items Correlated With Psychological Disorders During Recovery Period

Healthy Psychological
Category (GHQ ⬉ 6) disorders (GHQ ⭌ 7) OR 95% CI p

Respondent attributes
Gender
Female 60 (87.0) 9 (13.0) 1.0 1.6–9.3 .003ⴱⴱ
Male 77 (65.8) 40 (34.2) 3.2
Occupation
University student 77 (84.6) 14 (15.4) 1.0 1.4–6.7 .007ⴱⴱ
Other company staff, university staff 61 (63.5) 35 (36.5) 3.3
Treatment/isolation
No 108 (78.3) 30 (21.7) 1.0 1.4–7.5 .008ⴱⴱ
Yes 28 (63.6) 16 (36.4) 3.
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Symptoms
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Fever
No 135 (75.4) 44 (24.6) 1.0 1.5–41.9 .016ⴱ
Yes 2 (28.6) 5 (71.4) 7.9
Restrictions in daily life
Range of activities
No regulation 88 (85.4) 15 (14.6) 1.00 2.3–14.3 .000ⴱⴱⴱ
Regulation 47 (58.0) 34 (42.0) 5.7
Infection control
No regulation 81 (73.6) 29 (26.4) 1.0 0.1–0.9 .029ⴱ
Regulation 55 (73.3) 20 (26.7) 0.3
Eating
No regulation 103 (79.2) 27 (20.8) 1.0 1.7–14.6 .003ⴱⴱ
Regulation 35 (61.4) 22 (38.6) 5.0
Mask wearing
Yes 117 (77.5) 34 (22.5) 1.0 1.1–7.7 .029
No 20 (57.1) 15 (42.9) 2.93
Disinfection of clothing
No 112 (73.2) 41 (26.8) 1.00 0.0–0.5 .003ⴱⴱ
Yes 25 (75.8) 8 (24.2) 0.1
Going out
No regulation 79 (82.3) 17 (17.7) 1.0 1.4–5.3 .005ⴱⴱ
Regulation 56 (63.6) 32 (36.4) 3.8
Isolation
No 125 (75.3) 41 (24.7) 1.0 1.1–14.2 .042
Yes 12 (60.0) 8 (40.0) 3.9
Exercise and sport
No regulation 115 (73.7) 41 (26.3) 1.0 0.1–0.9 .037ⴱ
Regulation 23 (74.2) 8 (25.8) 0.3
Support
Income reduction
No 123 (83.7) 24 (16.3) 1.0 4.4–21.9 .000ⴱⴱⴱ
Yes 13 (34.2) 25 (65.8) 9.9
Recognition
Unknown impression
Low 116 (75.8) 37 (24.2) 1.0 0.9–7.3 .000ⴱⴱⴱ
High 11 (57.9) 8 (42.1) 2.6

Note. GHQ ⫽ General Health Questionnaire; OR ⫽ odds ratio; CI ⫽ confidence interval. A multivariate logistic regression analysis was performed for
each category. Variables entered from respondent attributes category: age, gender, involvement in health care sector, treatment/quarantine. Variables entered
from symptoms category: fever, cough, respiratory distress, muscular pain, headache, diarrhea. Variables entered from restrictions in daily life category:
range of activities, infection control, telephone, television, foods/clothing, bathing, smoking, eating, mask wearing, disinfection of clothing, going out,
quarantine, exercise and sport. Variables entered from support category: income reduction, medical/nursing care, support. Variables entered from cognition
category: knowledge, fear impression, unknown impression.
ⴱ
p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

disinfection of clothing, and infection control. The ORs were 3.2
for male gender, 5.5 for restricted range of activities, 3.9 for
restricted eating, 3.2 for restricted going out, and 25.0 for experi-
enced income reduction. Correlations opposite to our expectations
were observed in disinfection of clothing and infection control:
The ORs were 0.2 for performed disinfection of clothing and 0.1
for performed infection control, with the contribution being 87.7%.
Discussion
Attributes of Respondents
Respondents were mostly workers at universities or a printing
company and their families, with the mean age of the respondents
being 26.3 ⫾ 8.0 years, which means that they were within the
range of adolescence to early adulthood, an age at which people
 PSYCHOLOGICAL DISORDERS FOLLOWING SARS OUTBREAK 97

Table 3
Relationship Between Predictive Factors for Psychological Disorders During Recovery Period and Risk Control

Psychological disorders
Category Healthy (GHQ ⬉ 6) (GHQ ⭌ 7) OR 95% CI p

Fear impression
Low 15 (65.2) 3 (34.8) 1.0 0.4–13.0 .369
High 107 (73.8) 38 (2.24) 2.2
Unknown impression
Low 116 (75.8) 37 (24.2) 1.0 0.7–21.1 .127
High 11 (57.9) 8 (42.1) 3.8
Gender
Female 60 (87.0) 9 (13.0) 1.0 1.1–9.6 .040ⴱ
Male 77 (65.8) 40 (34.2) 3.2
Range of activities
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

No regulation 88 (85.4) 15 (14.6) 1.0 1.8–16.9 .003ⴱⴱ

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Regulation 47 (58.0) 34 (42.0) 5.5

Infection control
No regulation 81 (73.6) 29 (26.4) 1.0 0.0–0.5 .002ⴱ
Regulation 55 (73.3) 20 (26.7) 0.1
Eating
No regulation 103 (79.2) 27 (20.8) 1.0 1.1–14.4 .039ⴱ
Regulation 35 (61.4) 22 (38.6) 3.9
Disinfection of clothing
No 112 (73.2) 41 (26.8) 1.0 0.0–0.7 .011ⴱ
Yes 25 (75.8) 8 (24.2) 0.2
Going out
No 79 (82.3) 17 (17.7) 1.0 1.0–9.8 .047ⴱ
Regulation 56 (63.6) 32 (36.4) 3.2
Income reduction
No 123 (83.7) 24 (16.3) 1.0 6.0–105.1 .000ⴱⴱⴱ
Yes 13 (34.2) 25 (65.8) 25.0

Note. GHQ ⫽ General Health Questionnaire; OR ⫽ odds ratio; CI ⫽ confidence interval. Multivariate logistic regression analysis was performed for
items extracted from each category. Variables for forced-entry method: fear impression, unknown impression. Variables entered: gender, occupation,
treatment/quarantine, fever, range of activities, infection control, eating, mask wearing, disinfection of clothing, going out, quarantine, sport/exercise,
income reduction.
ⴱ
p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001. Contribution rate 87.7%.

are considered socially responsible. In terms of age and occupa-
tion, this was a highly localized group. The prevalence of SARS
was also low (2.1% to 5.9%), which puts limitations on assessing
the entire city of Beijing. In the 1998 mass outbreak of dysentery
in Japan, however, the sheer number of 3,090 infection suspects
was beyond the capacity of what the then infectious disease
prevention law could handle. For this reason, measures such as
isolation placed at a general hospital and home quarantine with
regular hospital visitation were employed: This action, which is
highly unorthodox in Japan, resulted from a bold decision of a
mayor. A GHQ-based survey of this case (Mihashi, 2001) reported
that the suspected or symptomless patients under home isolation
with regular hospital visits showed states of “anxiety, tension,
insomnia” and “depression” similar to the hospitalized patients.
The SARS outbreak with a 15% fatality inflicted an unprecedented
scale of broad quarantine on the entire city of Beijing. In this
sense, there is a limit to understanding the details of the whole
picture including the home quarantine. At the same time, however,
this group with the rare experience was significantly worth inves-
tigating to contribute to the future strategies for cohort isolation.
Comparison of GHQ–30 Scores in Isolation and
Recovery Periods
Daibou and Nakano (1987) reported that a group of healthy
university students in a general population survey showed 15%
psychological prevalence (scoring over 7). The frequency of psy-
chological disorder manifestation among the respondents in this
study (24.6%) was compared with that of previous studies (see
Table 4). The study of the dysentery outbreak in Nagasaki
(Mihashi, 2001) with 1,331 respondents reported the incidence of
psychological disorders as 21.8% (290 individuals), indicating that
the incidence of this study was significantly higher ( p ⬍ .05). In
surveys of 1,148 and 3,568 refugees after the 1995 Mt. Unzen
Fugendake volcanic eruption (Ota, 1996a, 1996b), psychological
disorders were observed in 68.0% and 67.0% of the respondents,
respectively; the incidences of psychological disorders were thus
higher than those in this study ( p ⬍ .001). The rate of psycholog-
ical disorder manifestation among the respondents in this study
was significantly lower than that in the case of a natural disaster,
such as a volcanic eruption, but significantly higher than that in the
case of the dysentery outbreak in Japan. Considering that the
fatality of SARS was 15% at that time, the results of this study are
reasonable and suggest the necessity of psychological care for
individuals who experienced isolation.
Predictive Factors for Onset of Psychological Disorders
The items obtained through analysis as the contributors to the
development of psychological disorder during the recovery period
were male gender, restricted range of activities, restricted eating,
restricted going out, and experiencing income reduction. The items
 98 MIHASHI ET AL.
Table 4
Onset of Psychological Disorders in Previous Japanese Studies
Number of Research
Author (year of publication) Object profile respondents scale
Watanabe (1989) Housewives who reside in an urban
area
Ota, Tsukahara, Sugasaki, General, middle-aged individuals
Katsuno, & Uemura (1993) aged 40 years or older
Mihashi (2001) Outbreak of dysentery
Ota, Y., Mine, M., Honda, A-bomb victims who are 45 years
S., Toriyama, H., & or older
Sugagaki, H. (1996)
Ota (1996a) Volcano eruption (Nagasaki, Japan)
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Ota (1996b) Volcano eruption (Nagasaki, Japan)
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Mihashi (Isolation period) Outbreak of
SARS (Beijing, China)
(Recovery period) Outbreak of
SARS (Beijing, China)
Note. GHQ–30 ⫽ 30-item General Health Questionnaire; ns ⫽ nonsignificant.
ⴱ
p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.
performed infection control and performed disinfection of clothing
demonstrated significant correlations, but in the opposite direction
from expected. In particular, the odds ratio of psychological dis-
order manifestation in income reduction was extremely high at
25.0. Because the printing company, where approximately two
thirds of the respondents in this study worked, paid wages to
workers on leave during the isolation period, it was assumed that
the university students and those with other occupations experi-
enced income reduction. With these circumstances, only a minor-
ity of respondents (28/285) actually experienced income reduction
when a long-term mass isolation was enforced. Under a cohort and
broad quarantine, distribution of common necessities may be de-
layed by transportation restrictions, which would raise anxieties and
complaints about daily life. Mihashi (2003) reported cases during the
1987 dysentery outbreak in Japan, where entire families were iso-
lated due to in-house infection and the dissatisfaction at being
unable to secure incomes escalated among breadwinners confined
to the hospital. If no financial security had been provided to any of
the respondents in this study, the incidence of psychological dis-
orders would have been much higher. Under such circumstances,
it is reasonable to assume that the financial condition of respon-
dents responsible for household financial management influences
the onset of psychological disorders; thus, financial security ap-
pears to be one of the most important factors in the future strate-
gies for mass isolation. Male gender was associated with neurosis.
A study of 209 market workers in China (Lee et al., 2005) reported
that male gender was associated with “punishing beliefs” of HIV.
It is consequently presumed that “male” in China is psychologi-
cally more influenced by infectious diseases with considerable
impact on daily lives.
Factors related to range of activities, eating, and going out are
involved in the fundamental desires of humans. Restrictions in
these matters had possibly exerted a strong influence on relatively
young individuals, such as the respondents in this study, who have
good appetites and a fairly wide range of daily activities. In a
future strategy, it is necessary to address the influences on daily
life by quickly identifying subjects’ characteristics.
Comparison of
Development of a psychological respondents
disorder (95% CI) chi-square test
6,198 GHQ–30 1,035/6,198 ⫽ 16.70% (15.78–17.64) p ⫽ .001ⴱⴱⴱ
339 GHQ–30 61/339 ⫽ 17.99% (14.09–22.26) p ⫽ .035ⴱ
1,331 GHQ–30 290/1,331 ⫽ 21.79% (19.61–24.05) p ⫽ .008ⴱⴱ
1,399 GHQ–30 318/1,399 ⫽ 22.73% (20.57–24.96) p ⫽ .334ns
1,148 GHQ–30 781/1,148 ⫽ 68.03% (65.31–70.70) p ⫽ .000ⴱⴱⴱ
3,564 GHQ–30 2,388/3,564 ⫽ 67.00% (65.45–68.54) p ⫽ .000ⴱⴱⴱ
191 GHQ–30 46/187 ⫽ 24.60% (18.71–31.01%) This object
187 GHQ–30 49/187 ⫽ 26.20% (20.17–32.73)
The factors for infection control and disinfection of clothing
were correlated in a direction opposite from expected. Disinfection
of clothing and infection control, such as hand washing, were
temporary and stress-free in daily life. Routine practice of these
activities in fact could lead to the prevention of infection, which in
effect decreased the possibility of psychological disorders.
The interview survey of SARS patients under isolation (Maunder et
al., 2003) reported that psychological effects, such as anxiety, un-
pleasantness due to nausea, and insomnia, were observed particu-
larly after developing fever. In the analysis of this study, although
the final outcome showed no factors related to symptoms, the odds
ratio and the contribution for having fever were 7.9 and 75.7%,
respectively. In this context, fever could be both physically and
psychologically influential, suggesting the necessity of providing
support for those who experience fever.
Furthermore, Maunder et al. (2003) reported that SARS patients
under isolation demanded the hospital for support, such as clear
communication, adjustment of regulations, and leadership with
authority. With regard to the correlates identified in this study that
directly cause inconvenience to personal life, that is, range of
activities, eating, and going out, it is essential to persuade people
that their cooperation should eventually lead to infection control,
thereby benefiting individual health. In this sense, it suggests that
clear ways to disseminate information and provide education are
important topics to explore. In addition, the promotion of disin-
fection of clothing and infection control measures, such as hand
washing, was effective, which suggested that in the future such
actions in isolation would contribute to mid- and long-term de-
creases in development of psychological disorders in the recovery
period. These hypotheses, however, require further empirical as-
sessment and validation.
Finally, to achieve risk control under broad quarantine, we force
entered the fear and the unknown impressions as predicting vari-
ables, and found low correlation of these with the psychological
disorder manifestation. Nevertheless, in a modern society and
circumstances with high risks, it is vital to control the concept of
risks (Okamoto, 1995). The survey by Brug et al. (2004) revealed
 PSYCHOLOGICAL DISORDERS FOLLOWING SARS OUTBREAK
that people with lower levels of education had stronger anxiety.
Among the respondents in this study, the stronger risk impression
resulted in higher odds ratios of psychological disorders. As a
consequence, it is of great importance to explore strategies that
effectively reduce risk impression, such as preparative, preventive
education and information dissemination after the events. Unilat-
eral and obsessive emphasis on psychological stability, on the
contrary, may undermine safety. With these ideas in mind, it is
important to adjust the balance between the correct recognition of
risks and defense actions, thus requiring further investigation in the
future.
Limitations of This Study
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This study involved a collective survey conducted during the
This document is copyrighted by the American Psychological Association or one of its allied publishers.
recovery period on the assumption that the impact of an over-
whelming social event, that is, the SARS outbreak, remains. No
questions were asked regarding private events that may have
influenced GHQ–30 scores at the time of the survey. Conse-
quently, potential biases outside the SARS outbreak and broad
quarantine are expected to exist in both the isolation and the
recovery periods. As a result, the suggested relations of GHQ–30
scores with the SARS outbreak and with the broad quarantine have
limited reliability.
The question items selected in this study as being predictors
were obtained from the possible contributors under the broad
quarantine environment due to infectious disease outbreak based
on the previous cases of mass outbreaks in Japan. When applied to
the residents of Beijing with different lifestyle, cultural values, cog-
nition of diseases, level of health care, medical care assurance, and
financial status from those of people in Japan, the questions and items
are expected to have somewhat limited appropriateness and validity.
Conclusion
A survey using a self-administered questionnaire was conducted
on workers of a printing company and students and faculty at
universities in Beijing, who experienced broad mass quarantine
following the 2003 SARS outbreak, to analyze the predicting
factors of psychological disorder manifestation in the recovery
period, 7 months after the isolation was lifted.
1. Among 187 respondents, 49 individuals (26.2%; 95% CI ⫽
20.2, 32.7) were identified as having psychological disorders in the
recovery period. The frequency of incidence was significantly
lower than that recorded among victims of a volcanic eruption but
significantly higher than that among patients under isolation dur-
ing a dysentery outbreak in Japan, suggesting the necessity of
psychological care for individuals who have experienced isolation.
2. With regard to predictive factors for the onset of psycholog-
ical disorders, male gender, restricted range of activities, restricted
eating, restricted going out, and experiencing income reduction
were obtained. Correlations opposite to our expectations were
observed for performed infection control and performed disinfec-
tion of clothing. The variable showing the highest correlation with
the psychological disorder development was income reduction.
The necessity of securing income is thus suggested to be important
in future strategies.
3. Fear and unknown impressions, which were set as predictive
variables for risk control in mass isolation, revealed low correla-
tion with the psychological disorder manifestation.
99
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Call for Nominations: Journal of Occupational Health Psychology

The Publications and Communications (P&C) Board of the American Psychological Association
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