The COVID-19 pandemic and subsequent mandatory quarantines in Italy significantly impacted psychological well-being, leading to increased rates of depression, anxiety, and insomnia. Cardiac patients, already at higher risk of severe COVID-19 complications and mortality, experienced further challenges due to isolation. Existing research shows a strong correlation between psychological distress (depression, anxiety, insomnia) and cardiac disease morbidity/mortality. While studies have documented the mental health impact on cardiac patients during the pandemic, a gap in knowledge existed regarding the specific effects of quarantine on their psychological outcomes post-cardiac intervention. This study aimed to fill this gap by longitudinally assessing depressive, anxiety, and insomnia symptoms in cardiac patients who underwent quarantine compared to a control group who did not experience quarantine during the same critical period (six to twelve months post-intervention). The hypothesis was that quarantined patients would exhibit more pronounced psychological symptoms.

The introduction thoroughly reviews the existing literature on the negative psychological impact of COVID-19 quarantine on the general population, highlighting increases in depression, anxiety, insomnia, and eating disorders. It also cites research demonstrating higher COVID-19 morbidity and mortality rates in cardiac patients and the negative impact of the pandemic on their mental health, even without direct COVID-19 infection. The literature strongly establishes the bidirectional relationship between psychological distress and cardiac disease, emphasizing that pre-existing psychological issues increase the risk of adverse outcomes in cardiac patients. The review concludes by highlighting the lack of research specifically on the impact of quarantine on post-cardiac intervention psychological outcomes, underscoring the rationale for this study.

This was a multicenter longitudinal study involving consecutive patients referred for cardiac rehabilitation between December 2017 and January 2020. 447 patients were initially approached, with 148 (39%) ultimately included in the quarantine group and 231 (61%) in the control group. Data attrition is detailed, with reasons for exclusion carefully documented (e.g., incomplete data, refusal to participate, inability to be contacted). The study adhered to the Declaration of Helsinki and obtained informed consent from all participants. Psychological assessments were performed at one month (assessment) and eight months (reassessment) post-cardiac intervention. Assessments involved a semistructured interview (at assessment only) gathering demographic, cardiac risk factor, and medication information; and questionnaires: Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and Sleep Condition Indicator (SCI). The age-adjusted Charlson Comorbidity Index (CCI) was also calculated. Statistical analyses included Student's t-tests and χ² tests for group comparisons, mixed-model repeated measures analyses for psychological outcomes (controlling for intervention type, CCI, and days post-intervention), and logistic regression to examine the influence of quarantine on clinically relevant symptoms. A power analysis ensured adequate sample size. The study followed rigorous ethical standards and data handling procedures.

The study found no significant baseline differences between the quarantine and control groups. Mixed-model analyses revealed a significant time × group interaction for BDI-II scores, indicating that the quarantine group exhibited significantly higher depressive symptoms at reassessment compared to the control group (p = 0.005). This effect was driven by a significant increase in cognitive depressive symptoms in the quarantine group (p = 0.003). At reassessment, a significantly higher proportion of patients in the quarantine group exhibited clinically relevant depression (30% vs. 9%, p = 0.002). Logistic regression confirmed that group membership significantly predicted the presence of clinically relevant depression at reassessment, even after controlling for baseline depression. Similar time × group interactions were observed for BAI scores, with the quarantine group showing higher anxiety at reassessment (p = 0.004). While there was a significant time effect for SCI scores (better sleep in the control group), a time × group interaction revealed lower sleep quality in the quarantine group at reassessment (p = 0.012). However, the difference in the presence of clinically relevant insomnia was not statistically significant between the groups.

The findings strongly suggest a negative impact of mandatory COVID-19 quarantine on the psychological health of cardiac patients during a crucial period for recovery and risk reduction. The increased prevalence of clinically significant depression in the quarantine group is particularly concerning, given the established association between depression and adverse cardiovascular outcomes. The results align with findings from studies on the general population and chronic disease patients experiencing quarantine, highlighting the vulnerability of cardiac patients to psychological distress. The study's findings emphasize the importance of integrating and improving psychological support within cardiac rehabilitation programs, particularly in the context of ongoing pandemics. The increased cognitive symptoms of depression in the quarantine group suggest a need for interventions targeting negative thought patterns and coping mechanisms.

This study provides the first longitudinal evidence of the detrimental effects of COVID-19-related quarantine on the psychological well-being of cardiac patients in the critical post-intervention period. The significant increase in depressive symptoms and the higher prevalence of clinically relevant depression in the quarantine group highlight the need for targeted and intensified mental health support in cardiac rehabilitation programs. Further research is warranted to investigate the specific mechanisms underlying these effects and to optimize mental health interventions for this vulnerable population.

The study's relatively small sample size, the absence of a healthy control group, and the lack of assessment of cardiovascular or functional outcomes at reassessment represent limitations. Although a power analysis indicated sufficient sample size to detect small effect sizes and the included participants were generally comparable to those excluded (except for slightly higher education in the included group), the findings may not be fully generalizable. Future research should utilize larger, more diverse samples and incorporate measures of cardiovascular and functional outcomes to fully understand the long-term impact of quarantine on this population.