{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T11:14:48Z","timestamp":1792062888002,"version":"4.4.0"},"reference-count":57,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2020,9,4]],"date-time":"2020-09-04T00:00:00Z","timestamp":1599177600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Resilience refers to an individual\u2019s healthy coping abilities when encountering adverse life events. The COVID-19 pandemic represents a situation with a high amount of stress exposure, which in turn may be associated with negative emotional outcome like depressive symptoms. The current study investigated if resilience moderated the effect of stress on symptoms of depression and if anxiety symptoms mediated this association. An adult sample of community controls completed the Perceived stress scale 14 (PSS-14), the Resilience scale for adults (RSA), the Patient health questionnaire 9 (PHQ-9) and the Generalized anxiety disorder 7 (GAD-7). Independent samples t-test, correlation analyses and moderated mediation analyses were conducted. The results showed that resilience moderated the relations between stress and anxiety symptoms (\u03b2 = \u22120.131, p &lt; 0.001) as well as between stress and depressive symptoms (\u03b2 = \u22120.068, p &lt; 0.05). In support of a moderated mediation model, resilience moderated the indirect effect of stress on depressive symptom, as confirmed by the index of moderated mediation (IMM = \u22120.036, p &lt; 0.001; [95% BCa: \u22120.055, \u22120.020]). The high resilience subgroup was less affected than the low resilience subgroup by the effect of stress exposure symptoms of depression, mediated by anxiety. The study shows that stress exposure is associated with symptoms of depression, and anxiety mediates this association. Level of resilience differentiates the direct and indirect effect of stress on depression. Knowledge about the effect of stress in response to a pandemic is important for developing treatment and prevention strategies for stress, depression and health-related anxiety.<\/jats:p>","DOI":"10.3390\/ijerph17186461","type":"journal-article","created":{"date-parts":[[2020,9,4]],"date-time":"2020-09-04T12:20:06Z","timestamp":1599222006000},"page":"6461","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":155,"title":["Resilience Moderates Negative Outcome from Stress during the COVID-19 Pandemic: A Moderated-Mediation Approach"],"prefix":"10.3390","volume":"17","author":[{"given":"Audun","family":"Havnen","sequence":"first","affiliation":[{"name":"Department of Psychology, Norwegian University of Science and Technology, 7491 Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0339-3263","authenticated-orcid":false,"given":"Frederick","family":"Anyan","sequence":"additional","affiliation":[{"name":"Department of Psychology, Norwegian University of Science and Technology, 7491 Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Odin","family":"Hjemdal","sequence":"additional","affiliation":[{"name":"Department of Psychology, Norwegian University of Science and Technology, 7491 Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stian","family":"Solem","sequence":"additional","affiliation":[{"name":"Department of Psychology, Norwegian University of Science and Technology, 7491 Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1294-9777","authenticated-orcid":false,"given":"Maja","family":"Gurigard Riksfjord","sequence":"additional","affiliation":[{"name":"Molde Hospital, M\u00f8re og Romsdal Hospital Trust, 6412 Molde, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4286-1277","authenticated-orcid":false,"given":"Kristen","family":"Hagen","sequence":"additional","affiliation":[{"name":"Molde Hospital, M\u00f8re og Romsdal Hospital Trust, 6412 Molde, Norway"},{"name":"Department of Mental Health, Norwegian University of Science and Technology, 7491 Trondheim, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,9,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"912","DOI":"10.1016\/S0140-6736(20)30460-8","article-title":"The Psychological Impact of Quarantine and How to Reduce It: Rapid Review of the Evidence","volume":"395","author":"Brooks","year":"2020","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1108\/17595901111108371","article-title":"Swine flu in Buenos Aires: Beyond the principle of resilience","volume":"2","author":"Korstanje","year":"2011","journal-title":"Int. J. Disaster Resil. Built Environ."},{"key":"ref_3","unstructured":"Nebehay, S., and Farge, E. (2020, April 13). Coronavirus Emergency Is \u2018Public Enemy Number 1\u2019, WHO via Reuters, Available online: https:\/\/www.reuters.com\/article\/us-china-health-who\/coronavirus-emer-gency-is-public-enemy-number-1-who-idUSKBN2050YV."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Taylor, S., and Asmundson, G.J.G. (2004). Treating Health Anxiety: A Cognitive Behavioral Approach, Guilford Press.","DOI":"10.1016\/S1077-7229(04)80015-4"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1002\/smi.1116","article-title":"Anxiety among university students during the SARS epidemic in Hong Kong","volume":"23","author":"Wong","year":"2006","journal-title":"Stress Health"},{"key":"ref_6","first-page":"1245","article-title":"The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital","volume":"168","author":"Maunder","year":"2003","journal-title":"Can. Med. Assoc. J."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1007\/s15010-008-7277-y","article-title":"Perceptions Related to Bird-to-Human Avian Influenza, Influenza Vaccination, and Use of Face Mask","volume":"36","author":"Lau","year":"2008","journal-title":"Infection"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1007\/s10608-011-9353-3","article-title":"Psychological Predictors of Anxiety in Response to the H1N1 (Swine Flu) Pandemic","volume":"36","author":"Wheaton","year":"2011","journal-title":"Cogn. Ther. Res."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"797","DOI":"10.1348\/135910710X485826","article-title":"Demographic and attitudinal determinants of protective behaviours during a pandemic: A review","volume":"15","author":"Bish","year":"2010","journal-title":"Br. J. Health Psychol."},{"key":"ref_10","unstructured":"Lazarus, S.R., and Folkman, S. (1984). Stress, Appraisal, and Coping, Springer."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1017\/S1474746408004594","article-title":"Resilience and social exclusion","volume":"8","author":"Mohaupt","year":"2009","journal-title":"Soc. Policy Soc."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"517","DOI":"10.1017\/S0954579400006131","article-title":"Resilience as process","volume":"5","author":"Egeland","year":"1993","journal-title":"Dev. Psychopathol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"598","DOI":"10.1192\/bjp.147.6.598","article-title":"Resilience in the Face of Adversity: Protective factors and resistance to psychiatric disorder","volume":"147","author":"Rutter","year":"1985","journal-title":"Br. J. Psychiatry"},{"key":"ref_14","first-page":"739","article-title":"Resilience in development: A synthesis of research across five decades","volume":"Volume 3","author":"Cicchetti","year":"2006","journal-title":"Developmental Psychopathology: Risk, Disorder, and Adaptation"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Masten, A.S., and Obradovi\u0107, J. (2008). Disaster Preparation and Recovery: Lessons from Research on Resilience in Human Development. Ecol. Soc., 13.","DOI":"10.5751\/ES-02282-130109"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1017\/S0954579412000028","article-title":"Resilience as a dynamic concept","volume":"24","author":"Rutter","year":"2012","journal-title":"Dev. Psychopathol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1037\/0033-2909.129.1.10","article-title":"Understanding the association between socioeconomic status and physical health: Do negative emotions play a role?","volume":"129","author":"Gallo","year":"2003","journal-title":"Psychol. Bull."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1027\/1016-9040\/a000124","article-title":"Psychological Resilience: A review and critique of definitions, concepts, and theory","volume":"18","author":"Fletcher","year":"2013","journal-title":"Eur. Psychol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1016\/j.cpr.2017.11.002","article-title":"Intervention studies to foster resilience\u2014A systematic review and proposal for a resilience framework in future intervention studies","volume":"59","author":"Chmitorz","year":"2018","journal-title":"Clin. Psychol. Rev."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1002\/mpr.143","article-title":"A new rating scale for adult resilience: What are the central protective resources behind healthy adjustment?","volume":"12","author":"Friborg","year":"2003","journal-title":"Int. J. Methods Psychiatry Res."},{"key":"ref_21","first-page":"310","article-title":"Preliminary results from the development and validation of a Norwegian scale for measuring adult resilience","volume":"38","author":"Hjemdal","year":"2001","journal-title":"J. Nor. Psychol. Assoc."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1002\/mpr.15","article-title":"Resilience in relation to personality and intelligence","volume":"14","author":"Friborg","year":"2005","journal-title":"Int. J. Methods Psychiatry Res."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1016\/j.chc.2006.12.003","article-title":"Measuring Protective Factors: The Development of Two Resilience Scales in Norway","volume":"16","author":"Hjemdal","year":"2007","journal-title":"Child Adolesc. Psychiatr. Clin. N. Am."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1037\/0033-2909.116.3.429","article-title":"Gender differences in personality: A meta-analysis","volume":"116","author":"Feingold","year":"1994","journal-title":"Psychol. Bull."},{"key":"ref_25","unstructured":"Beall, A.E., and Sternberg, R.J. (1993). Gender in thought, belief, and action: A cognitive approach. The Psychology of Gender, Guilford Press."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1111\/j.1939-0025.1989.tb01636.x","article-title":"High-risk children in young adulthood: A longitudinal study from birth to 32 years","volume":"59","author":"Werner","year":"1989","journal-title":"Am. J. Orthopsychiatry"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"581","DOI":"10.1037\/0003-066X.60.6.581","article-title":"The gender similarities hypothesis","volume":"60","author":"Hyde","year":"2005","journal-title":"Am. Psychol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"194","DOI":"10.1002\/cpp.488","article-title":"Resilience predicting psychiatric symptoms: A prospective study of protective factors and their role in adjustment to stressful life events","volume":"13","author":"Hjemdal","year":"2006","journal-title":"Clin. Psychol. Psychother."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"174","DOI":"10.1111\/j.1467-9450.2011.00928.x","article-title":"Resilience is a good predictor of hopelessness even after accounting for stressful life events, mood and personality (NEO-PI-R)","volume":"53","author":"Hjemdal","year":"2011","journal-title":"Scand. J. Psychol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"745","DOI":"10.1002\/da.20558","article-title":"Psychological resilience and postdeployment social support protect against traumatic stress and depressive symptoms in soldiers returning from Operations Enduring Freedom and Iraqi Freedom","volume":"26","author":"Pietrzak","year":"2009","journal-title":"Depress. Anxiety"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"314","DOI":"10.1002\/cpp.719","article-title":"The relationship between resilience and levels of anxiety, depression, and obsessive-compulsive symptoms in adolescents","volume":"18","author":"Hjemdal","year":"2010","journal-title":"Clin. Psychol. Psychother."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1037\/0278-6133.27.5.659","article-title":"Psychological resilience and dysfunction among hospitalized survivors of the SARS epidemic in Hong Kong: A latent class approach","volume":"27","author":"Bonanno","year":"2008","journal-title":"Health Psychol."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Rosenberg, A.R. (2020). Cultivating Deliberate Resilience During the Coronavirus Disease 2019 Pandemic. JAMA Pediatrics.","DOI":"10.1001\/jamapediatrics.2020.1436"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1016\/j.jad.2017.12.011","article-title":"Specificity in mediated pathways by anxiety symptoms linking adolescent stress profiles to depressive symptoms: Results of a moderated mediation approach","volume":"228","author":"Anyan","year":"2017","journal-title":"J. Affect. Disord."},{"key":"ref_35","unstructured":"Hayes, A.F. (2013). Mediation, Moderation, and Conditional Process Analysis, Guilford Publications."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1080\/00273171.2014.962683","article-title":"An Index and Test of Linear Moderated Mediation","volume":"50","author":"Hayes","year":"2015","journal-title":"Multivar. Behav. Res."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1080\/00273170701341316","article-title":"Addressing Moderated Mediation Hypotheses: Theory, Methods, and Prescriptions","volume":"42","author":"Preacher","year":"2007","journal-title":"Multivar. Behav. Res."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1016\/j.ajp.2017.04.019","article-title":"Anxiety symptoms mediate the relationship between exposure to stressful negative life events and depressive symptoms: A conditional process modelling of the protective effects of resilience","volume":"29","author":"Anyan","year":"2017","journal-title":"Asian J. Psychiatry"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho, C.S.H., and Ho, R. (2020). Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17051729"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1016\/S2215-0366(20)30168-1","article-title":"Multidisciplinary research priorities for the COVID-19 pandemic: A call for action for mental health science","volume":"7","author":"Holmes","year":"2020","journal-title":"Lancet Psychiatry"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1146\/annurev-soc-071913-043237","article-title":"The Far-Reaching Impact of Job Loss and Unemployment","volume":"41","author":"Brand","year":"2015","journal-title":"Annu. Rev. Sociol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"385","DOI":"10.2307\/2136404","article-title":"A Global Measure of Perceived Stress","volume":"24","author":"Cohen","year":"1983","journal-title":"J. Health Soc. Behav."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1016\/j.anr.2012.08.004","article-title":"Review of the Psychometric Evidence of the Perceived Stress Scale","volume":"6","author":"Lee","year":"2012","journal-title":"Asian Nurs. Res."},{"key":"ref_44","first-page":"BC10","article-title":"Study on Serum Cortisol and Perceived Stress Scale in the Police Constables","volume":"9","author":"Walvekar","year":"2015","journal-title":"J. Clin. Diagn. Res."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1016\/j.jpsychores.2005.12.007","article-title":"Resilience as a moderator of pain and stress","volume":"61","author":"Friborg","year":"2006","journal-title":"J. Psychosom. Res."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1092","DOI":"10.1001\/archinte.166.10.1092","article-title":"A Brief Measure for Assessing Generalized Anxiety Disorder","volume":"166","author":"Spitzer","year":"2006","journal-title":"Arch. Intern. Med."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1016\/j.janxdis.2014.06.002","article-title":"Beyond generalized anxiety disorder: Psychometric properties of the GAD-7 in a heterogeneous psychiatric sample","volume":"28","author":"Beard","year":"2014","journal-title":"J. Anxiety Disord."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1713","DOI":"10.3389\/fpsyg.2019.01713","article-title":"Psychometric properties of the GAD-7 in a heterogeneous psychiatric sample","volume":"10","author":"Johnson","year":"2019","journal-title":"Front. Psychol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"606","DOI":"10.1046\/j.1525-1497.2001.016009606.x","article-title":"The PHQ-9\u2014Validity of a brief depression severity measure","volume":"16","author":"Kroenke","year":"2001","journal-title":"J. Gen. Intern. Med."},{"key":"ref_50","unstructured":"Muth\u00e9n, K.L., and Muth\u00e9n, B.O. (2017). Mplus: Statistical Analysis with Latent Variables (Version 7.4), Muth\u00e9n & Muth\u00e9n."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1016\/j.jad.2016.05.031","article-title":"Adolescent stress and symptoms of anxiety and depression: Resilience explains and differentiates the relationships","volume":"203","author":"Anyan","year":"2016","journal-title":"J. Affect. Disord."},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Hagen, K., Solem, S., Opstad, H.B., Hansen, B., and Hagen, R. (2017). The role of metacognition and obsessive-compulsive symptoms in psychosis: An analogue study. BMC Psychiatry, 17.","DOI":"10.1186\/s12888-017-1392-1"},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"Solem, S., Thunes, S.S., Hjemdal, O., Hagen, R., and Wells, A. (2015). A Metacognitive Perspective on Mindfulness: An Empirical Investigation. BMC Psychol., 3.","DOI":"10.1186\/s40359-015-0081-4"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1023\/A:1025638705649","article-title":"Underemployment: Consequences for the health and well-being of workers","volume":"32","author":"Friedland","year":"2003","journal-title":"Am. J. Community Psychol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1007\/s11126-016-9460-0","article-title":"Employment Status and Mental Health: Mediating Roles of Social Support and Coping Strategies","volume":"88","author":"Perreault","year":"2016","journal-title":"Psychiatr. Q."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1080\/15305058.2010.508570","article-title":"The Resilience Scale for Adults: Construct Validity and Measurement in a Belgian Sample","volume":"11","author":"Hjemdal","year":"2011","journal-title":"Int. J. Test."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"23970","DOI":"10.3402\/ejpt.v5.23970","article-title":"Psychosocial facets of resilience: Implications for preventing posttrauma psychopathology, treating trauma survivors, and enhancing community resilience","volume":"5","author":"Iacoviello","year":"2014","journal-title":"Eur. J. Psychotraumatol."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/18\/6461\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T10:06:57Z","timestamp":1760177217000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/18\/6461"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,9,4]]},"references-count":57,"journal-issue":{"issue":"18","published-online":{"date-parts":[[2020,9]]}},"alternative-id":["ijerph17186461"],"URL":"https:\/\/doi.org\/10.3390\/ijerph17186461","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,9,4]]}}}