http://jppbr.
DOI: 10.
21776/ub.
eISSN: 2723-083X pISSN: 2723-0821 Journal of Psychiatry Psychology and Behavioral Research Vol.
7 No.
March 2026
JPPBR
PATH ANALYSIS OF FACTORS AFFECTING STRESS,
ANXIETY AND DEPRESSION IN MEDICAL RESIDENTS
DURING THE COVID-19 PANDEMIC
Aziza Matinu Karima.
1 Gst.
Ayu Maharatih.
2 IGB.
Indro Nugroho2 Correspondence: aziza.
karima@gmail.
1Department of Psychiatry.
General Hospital Dr.
Saiful Anwar.
East Java.
Indonesia 2Department of Psychiatry.
Dr.
Moewardi Regional General Hospital.
Surakarta.
Indonesia
RESEARCH
OPEN ACCESS
ABSTRACT
Introduction: The COVID-19 pandemic has significantly affected the mental health of medical personnel, particularly residents who face high clinical workloads, exposure risks, and academic pressures.
The aim of this research to analyze direct and indirect determinants of stress, anxiety, and depression among medical residents using path analysis.
Methods: A cross-sectional study involving 437 residents at Dr.
Moewardi Hospital was conducted in OctoberAeNovember 2020.
Stress, anxiety, and depression were assessed using the DASS-21, while coping mechanisms were measured using the Brief COPE.
Data analysis was conducted using path analysis.
Results: Stress ( = 0.
p < 0.
and anxiety ( = 0.
p < 0.
directly increased depression, while adaptive coping showed a negative association ( = Ae1.
p < 0.
Age, sex, comorbidities, and COVID-19 exposure had indirect effects mediated by stress and anxiety.
Discuss: The findings of this study underscore the importance of interventions that reinforce adaptive coping, including stress management training, mindfulness, peer support, and religious approaches.
Conclusion: Stress and anxiety significantly predicted depression, while adaptive coping had a protective effect.
Keywords: stress, anxiety, depression, coping, medical residents.
COVID-19.
Article History:
Received: January 20, 2026 Accepted: March 28, 2026 Published: March 31, 2026 Cite this as: Karima.
Maharatih.
Nugoroho.
Path Analysis of Factors Affecting Stress.
Anxiety and Depression in Medical Residents during the COVID-19 Pandemic.
Journal of Psychiatry.
Psychology, and Behavioral Research.
7:1.
Theoretically, stress, anxiety, and depression have a close interaction in emotional responses to environmental pressures.
The stressAeappraisalAecoping model by Lazarus and Folkman explains that stress arises when environmental demands exceed an individual's ability to adapt.
9 When chronic, stress can trigger anxiety and eventually develop into depression, consistent with physiological evidence regarding the dysregulation of the nervous system, neurotransmitters, and the hypothalamic-pituitary-adrenal (HPA) axis.
Coping mechanisms play a crucial role in determining whether an individual can adapt in a healthy way.
Adaptive coping strategies such as planning, positive reframing, and religious coping have been proven to reduce the risk of depression, 14-16, whereas maladaptive coping strategies such as denial, venting, and behavioral disengagement actually increase the risk of psychological disorders.
Although many studies have reported high levels of psychological distress among healthcare workers during the pandemic,5-7 studies assessing the structural relationship
between demographic factors, coping mechanisms, stress, anxiety, and depression among medical residents in Indonesia
INTRODUCTION
The Coronavirus Disease 2019 (COVID-.
pandemic has had a major impact on the healthcare system and the psychological well-being of medical personnel.
Doctors and healthcare workers are on the front lines facing rising cases, limited facilities, and a high risk of infection exposure, all of which cause significant psychological pressure.
1-4 Various international studies indicate that more than half of healthcare workers experienced symptoms of stress, anxiety, and depression during the peak of the pandemic, making this group a highly vulnerable population.
In Indonesia, doctors in the Specialist Doctor Education Program (PPDS/Resident.
face a double burden of academic demands, long shift hours, and infection risk.
A survey by the Indonesian Psychiatric Association (IPA as known as PDSKJI [Perhimpunan Dokter Kesehatan Jiwa Indonesi.
) showed a high prevalence of anxiety, depression, and post-traumatic stress among healthcare workers during the pandemic.
8 This condition places medical residents at risk of significant psychological distress.
remain limited.
This study aims to evaluate the direct and indirect effects of these factors using path analysis.
METHOD
Study Design This research is a cross-sectional study conducted in OctoberAe November 2020 at Dr.
Moewardi Regional General Hospital.
Surakarta.
Population and Sample The study population consisted of all active medical residents (PPDS I).
A total of 437 respondents met the inclusion criteria and agreed to participate in the study.
Research Instruments DASS-21 was developed by Lovibond & Lovibond.
This instrument was used to assess stress, anxiety, and depression.
The Indonesian version has been tested for validity and reliability by Damanik, with CronbachAos alpha>0.
70 across all three subscales.
Brief COPE, based on the model by Lazarus & Folkman, was used to assess adaptive and maladaptive coping.
Previous coping research has shown good construct validity, and religious coping has shown significant validity in the Indonesian population.
Conceptual Framework The conceptual framework in this study explains that during the COVID-19 pandemic, all aspects of a person's life, starting from gender, age, how many semesters a resident has studied, marital status, family factors including living with family or not during specialist medical education, economic factors including school fees, smoking or alcohol consumption history, comorbid factors of a resident, how often and close to exposure to the coronavirus, and whether the resident has ever been infected with the coronavirus or not, will affect a person's Covid-19 outbreak/phenomenon.
The use of adaptive or maladaptive coping will certainly affect a person's stress level, so that it can result in him experiencing anxiety disorders and/or depression, or he can successfully overcome this COVID-19 pandemic phenomenon well.
This has encouraged researchers to further investigate the direct and indirect influence of various variables on stress, anxiety, and depression in medical residents [Figure .
Analysis Procedure Data analysis was performed using path analysis to test the direct and indirect influences between components.
Bivariate tests .
hi-square and Pearson correlatio.
were performed prior to modeling.
The path analysis procedure was chosen in this study because it allows testing causal relationships among variables with both direct and indirect influences .
hrough intermediary variable.
Furthermore, path analysis can provide us with a visualization of the causal relationship model between variables created from the research results Ethical Consideration Written informed consent for publication was obtained from the respondents after a full explanation of the purpose and scope of this research.
Ethical clearance for this research was granted by the Health Research Ethics Committee.
Dr.
Moewardi General Hospital.
RESULT
Respondent Characteristics The average age of respondents was 33 A 3.
6 years.
were male.
1% had high exposure to COVID-19 patients.
65% had chronic comorbidities.
Symptoms of stress were experienced by 58.
6% of respondents, anxiety by 54%, and depression by 47.
2%, with the majority falling into the mild-to-moderate category.
Based on table 1 and 2, it can be seen that the majority of respondents are male .
4%), most are in the middle semester between semesters 3 and 4 .
2%),
9%), live with family .
1%), do not smoke .
9%), do not drink alcohol .
5%), funding source from parents/self .
, close to exposure to Covid .
1%), do not have comorbid diseases .
35%), have never been infected .
9%), and the medical residents that most fills in is Psychiatry .
2%).
Bivariate Results Stress correlated positively with anxiety .
= 0.
p < 0.
and depression .
= 0.
p < 0.
then anxiety correlated positively with depression .
= 0.
p < 0.
Another result reveals that adaptive coping correlated negatively with depression .
= Ae1.
p < 0.
, and then COVID-19 exposure, female gender, and comorbidities were significantly associated with stress and anxiety levels .
< 0.
From Table 3, it can be seen that stress has a positive correlation with depression .
= 0.
p < 0.
coping mechanisms have a negative correlation .
= -1.
p < 0.
From Table 4, it can be seen that stress has a positive correlation with anxiety .
= 0.
COVID-19 exposure, female gender, and comorbidities were significantly associated with stress and anxiety levels .
< 0.
Path Analysis The final model showed a good fit.
Significant path coefficients included: Stress Ie Depression ( = 0.
Anxiety Ie Depression ( = 0.
p < 0.
Adaptive Coping Ie Depression ( = Ae1.
p < 0.
Demographic factors had indirect effects through stress and anxiety.
Figures 2 and 3 show that depression is directly influenced by anxiety, coping mechanisms, and stress.
Coping mechanisms directly decreased the likelihood of depression by 2 units and were statistically significant .
= -1.
95% CI
= -1.
59 to -0.
p = 0.
Anxiety directly increased the likelihood of depression by 0.
18 units and was statistically significant .
= 0.
95% CI = 0.
07 to 0.
p = 0.
Stress directly increased the likelihood of depression by 0.
units, with a statistically significant effect .
= 0.
95% CI =
40 to 0.
p = 0.
Depression is indirectly influenced by age, exposure, gender, and comorbidities, where: .
Age increases the likelihood of using coping mechanisms by 0.
13 units and is statistically highly significant .
= 0.
95% CI = 0.
05 to 0.
p < 0.
Coping mechanisms decrease the likelihood of stress by 3.
units and is statistically significant .
= -3.
95% CI = -3.
p < 0.
Coping mechanisms decrease the likelihood of anxiety by 0.
38 units and is statistically highly significant .
= -0.
95% CI = -0.
75 to -0.
p < 0.
Stress increased the likelihood of anxiety by 0.
68 units and was statistically highly significant .
=0.
95% CI=0.
63 to 0.
p<0.
Exposure increased the likelihood of anxiety by 34 units and was statistically highly significant .
=0.
CI=0.
02 to 0.
p<0.
Gender increased the likelihood of anxiety by 0.
29 units and was statistically highly significant .
=0.
95% CI=0.
01 to 0.
p<0.
Comorbidity increased the likelihood of anxiety by 0.
32 units and was statistically significant .
= 0.
95% CI= -0.
00 to 0.
p<0.
DISCUSS
This study demonstrates that stress and anxiety are strong predictors of depression in medical residents during the COVID-19 pandemic.
These findings align with various international studies highlighting the high prevalence of mental health issues among healthcare workers during the 5-7 Increased workload, infection risk, and academic pressure reinforce medical residents' psychological The strong correlation between stress, anxiety, and depression supports the conceptual framework of Lazarus and Folkman,9 which emphasizes the role of coping mechanisms in determining individual emotional responses.
Various previous studies have also shown the link between prolonged stress and the emergence of anxiety and depression,10-11 illustrating a progressive pattern of psychological distress.
Physiologically, chronic stress can cause continuous activation of the HPA axis, disturbances in cortisol secretion, and changes in neurotransmitter systems such as serotonin and dopamine.
These mechanisms have been linked to the development of depression in neuropsychiatric 12,13 This study also confirms the protective role of adaptive coping Strategies such as planning, positive reframing, and religious coping proved helpful for individuals in managing stress constructively.
These findings are consistent Table 1.
Characteristics of Subjects Characteristic Gender Semester Marital Status Residence Tuition Funding Smoking History Alcohol History COVID Exposure Comorbidities Infected with COVID Study program with previous research,14-16 showing that adaptive coping can reduce psychological distress in various populations, including healthcare workers.
Conversely, maladaptive coping such as denial and venting is associated with increased emotional distress, as reported in prior studies.
10-11 This underscores that it is not only the level of stress that matters, but also how individuals interpret and respond to it.
Demographic factors such as female gender and COVID-19 exposure showed indirect relationships with depression through increased stress and anxiety.
This finding is consistent with international research regarding healthcare worker groups that have higher psychological risks.
The findings of this study underscore the importance of interventions that reinforce adaptive coping, including stress management training, mindfulness, peer support, and religious Evidence from research in Indonesia shows that religious coping is effective in reducing depressive symptoms during the pandemic.
However, this study has limitations, including a cross-sectional design that does not allow for strong causal inference and reliance on self-report instruments, which are prone to bias.
Nevertheless, the strength of this study lies in its large sample size and the use of path analysis, which can comprehensively describe the direct and indirect effects among variables.
Category Male Female Junior Middle Senior Chief >8 semesters Single Married Widowed/Divorced Alone With Family Self Parents Scholarship Never < 2 cigarettes 1 pack Never Rare Several drinks/week Not Close Close Very Close None Present Sick Cardiovascular Disease Anesthesiology Internal Medicine Radiology Psychiatry THT-KL Health Sciences Obstetrics and Gynecology Surgery Orthopedics and Traumatology Pediatrics Pulmonology Neurology Dermatology and Venereology Clinical Pathology Total Table 2.
Univariate Analysis Results of Categorical Data Variable Gender Female Male Marital Status Married Single Residence Alone With family Smoking Yes Frequency .
Percentage (%) Variable Alcohol Consumption Yes Funding Source Scholarship Self/Parents COVID-19 Exposure Risk Low High COVID-19 Infection Status Yes Frequency .
Percentage (%) Table 3.
Characteristics of the relationship between stress, coping mechanisms, gender, comorbidities.
COVID-19 infection, exposure, smoking, marriage, residence, age, semester, financing with depression.
Depression Variable Stress
Coping Mechanisms Gender
Comorbidities COVID-19 Infection
Exposure Smoking Marriage Residence Age
Semester Financing Scholarship
% CI]
710275 -.
9785967 -.
Table 4.
Characteristics of the relationship between stress, coping mechanisms, gender, comorbidities.
COVID-19 infection, exposure, smoking, marriage, residence, age, semester, and financing with anxiety.
Anxiety Variabel .
% C.
Stress Coping Mechanisms Gender Comorbidities COVID-19 Infection Exposure Smoking Marriage Residence Age Semester Financing Scholarship Figure 1.
Conceptual Framework Figure 2.
Results of path analysis between stress, anxiety, depression, coping mechanisms, age, exposure, gender, and Figure 3.
Path analysis model of stress, anxiety, and depression with coping mechanisms and demographic factors CONCLUSION Stress and anxiety are the main predictors of depression in medical residents during the COVID-19 pandemic, while adaptive coping mechanisms have a significant protective Demographic factors have an indirect effect on depression through stress and anxiety.
Medical education institutions and hospitals need to develop comprehensive psychological support programs, including stress management training, strengthening of adaptive coping, spiritual support, and peer support systems.
Longitudinal research is needed to assess long-term psychological REFERENCES