The COVID-19 pandemic placed immense stress on healthcare workers (HCWs) globally, leading to increased symptoms of stress, anxiety, and depression. The pandemic disrupted daily life, causing generalized fear, anxiety, and uncertainty, exacerbated by isolation measures reducing social support, crucial for emotional regulation and resilience. HCWs already experience high distress levels under normal circumstances, and the pandemic further heightened risks, including infection, fear of infecting loved ones, emotional strain, extended shifts, and exhaustion. These psychological burdens negatively impact mental health, particularly for frontline workers. Studies show significant levels of stress, anxiety, depression, and insomnia among HCWs due to the pandemic, influenced by psychological and sociodemographic factors. This study investigates the role of resilience and mentalizing capacity—the ability to understand one's own and others' mental states—in mitigating these mental health symptoms. Resilience is the ability to adapt to and recover from stressful experiences, involving individual characteristics, biological factors, and environmental factors. Mentalizing, while important for resilience, can be impaired through hypomentalizing (lack of assumptions about mental states) or hypermentalizing (excessive assumptions). This study aims to determine if resilience and mentalizing capacity explain levels of depression, anxiety, and stress among HCWs during the COVID-19 pandemic in Serbia, hypothesizing significant relationships between these variables and HCWs' mental health.

Existing literature highlights the significant mental health burden on healthcare workers during the COVID-19 pandemic, with increased rates of depression, anxiety, and stress. Studies have identified several risk factors, including prolonged exposure to stressors, fear of infection, lack of social support, and demanding work conditions. Previous research has also explored the protective role of resilience in mitigating the negative impact of stress on mental health. Resilience has been defined as the ability to adapt effectively and recover from challenging circumstances, encompassing individual characteristics, biological predispositions, and environmental factors. Furthermore, the capacity for mentalizing, the ability to understand one's own and others' mental states, has been increasingly recognized as a crucial component of resilience and a protective factor against mental health problems. However, research specifically investigating the interplay between mentalizing, resilience, and mental health outcomes in HCWs during the COVID-19 pandemic is limited, particularly in the context of different mentalizing styles (hypomentalizing and hypermentalizing).

This cross-sectional study employed a quantitative approach, collecting data from a sample of 406 HCWs (141 doctors and 265 nurses) in Serbia between July 15, 2021, and February 5, 2022. The sample size was determined using the Raosoft Sample Size Calculator. Participants were recruited from the University Clinical Center Kragujevac and provided written informed consent. Data were collected using a paper-and-pencil survey method. The Depression, Anxiety, and Stress Scale (DASS-42) measured depression, anxiety, and stress; the Brief Resilience Scale (BRS) assessed resilience; and a shortened version of the Reflective Functioning Questionnaire (RFQ-8) measured mentalizing capacity (hypermentalizing and hypomentalizing). A separate questionnaire gathered sociodemographic, work-related, and COVID-19-related characteristics. Data were analyzed using descriptive statistics, Pearson's correlation coefficients, and hierarchical linear regression analysis. The hierarchical regression included control variables (gender, age, profession, work environment, socioeconomic status, marital status, number of children) and predictor variables (resilience, hypermentalizing, and hypomentalizing) to determine their predictive power on depression, anxiety, and stress. Assumptions of normality, linearity, multicollinearity, and homogeneity of variance were checked before regression analysis.

The study found that the majority of participants were female nurses who were married and reported a good socioeconomic status. The DASS-42, BRS, and RFQ-8 scales demonstrated good reliability (Cronbach's alpha > 0.70). Correlation analysis revealed significant negative correlations between resilience and all three mental health dimensions (depression, anxiety, stress). Hypermentalizing was negatively correlated, and hypomentalizing positively correlated with these dimensions. Hierarchical linear regression analysis showed that resilience and hypermentalizing significantly predicted lower levels of depression, anxiety, and stress, while hypomentalizing significantly predicted higher levels. Socioeconomic status also significantly predicted lower levels of depression, anxiety, and stress. Other sociodemographic variables (marital status, number of children, work environment) were not significant predictors. Specifically, the regression models explained 37%, 41%, and 43% of the variance in depression, anxiety, and stress respectively, after controlling for the influence of the other variables. The impact of resilience on the different mental health measures was consistently significant, while the impacts of hyper- and hypomentalizing were also significant but to a lesser extent. For example, when accounting for control variables the socioeconomic status was a significant negative predictor of depression (β = −0.30, p < 0.01), meaning that higher socioeconomic status implied less depression among HCWs. The finding that hypermentalizing was an important negative predictor of stress indicated that a higher degree of confidence in one's own ability to accurately assess intentional mental states reduced the degree of experiencing stress.

The findings confirm the protective role of resilience in mitigating mental health problems among HCWs during the pandemic, aligning with previous research. Higher resilience was associated with lower levels of depression, anxiety, and stress. The study also provides novel evidence on the role of mentalizing capacity. Impaired mentalizing, particularly hypomentalizing, was linked to increased mental health problems, suggesting that the ability to understand one's own and others' mental states is crucial for coping with pandemic-related stress. Conversely, hypermentalizing, while not necessarily optimal, showed a protective effect against mental health issues. These findings support the importance of fostering resilience and improving mentalizing skills among HCWs to improve mental well-being and enhance their ability to manage stressful situations. The results support the need for interventions that improve resilience and address mentalizing capacity deficits, particularly hypomentalizing, to help HCWs better navigate occupational challenges and minimize their risk of mental health issues.

This study demonstrates the crucial roles of resilience and mentalizing capacity in protecting HCWs' mental health during the COVID-19 pandemic. Resilience and hypermentalizing were protective factors, while hypomentalizing exacerbated mental health problems. These findings underscore the need for interventions focused on enhancing resilience and mentalizing skills to mitigate the negative mental health consequences of stressful events on HCWs. Future research could explore specific interventions to improve resilience and mentalizing abilities, and examine the long-term effects of the pandemic on HCWs' mental health. Further investigation is needed on larger and more diverse samples to confirm generalizability and to understand how cultural context influences these findings.

This study's cross-sectional design limits causal inferences, and the sample was drawn from a single hospital, limiting generalizability to other HCW populations. Self-reported data are susceptible to response biases, potentially affecting the findings. Further research is needed to investigate factors related to COVID-19 and their impact on HCWs' mental health, and to test interventional strategies to improve resilience and mentalizing capacities.