Psychological distress and treatment preferences among parents amidst the COVID-19 pandemic

The COVID-19 pandemic has presented many stressors for parents. This study was conducted to examine treatment preferences and barriers to care amidst COVID-19. Parents (N = 95) completed self-report measures. Education was provided on interventions (e.g., individual therapy, medication), and acceptability assessed. Elevated stress and distress were observed. Parents indicated interest in services for parenting concerns, stress, anxiety, and depression. Individual therapy and telehealth were highly acceptable, while medication and group therapy were less accepted. Findings highlight the need for specific supports among parents amidst the pandemic. Factors that influence treatment preference warrant further attention. Implications for healthcare service delivery are discussed.

The COVID-19 pandemic resulted in immense challenges and adverse effects on for mental health worldwide (Calvano et al., 2021;Vindegaard and Benros, 2020). Parents have faced significant burden, with individuals navigating the perinatal period experiencing unique stressors and mental health risks while juggling the demands of pregnancy, childbirth, and caregiving in the context of a global health crisis (Osborne et al., 2021). Broadly, COVID-related stressors have been linked with deterioration in parental well-being and increased risks for burnout, domestic violence, and child maltreatment (Griffith, 2020). Moreover, emerging data indicate that pandemic rates of psychological distress significantly exceed pre-pandemic norms (Ostacoli et al., 2020), with notable escalations observed among caregivers and perinatal populations (Suwalska et al., 2021;Thompson and Bardone-Cone, 2021). Thus, effective psychological supports for parents and families are needed.
Despite calls for guidelines to address the psychological impacts of the pandemic on families (Fontanesi et al., 2020), to our knowledge, no study has examined the most common presenting concerns or preferences for psychological services among parents during COVID-19. Yet, a study on maternal mental health service utilization during the pandemic revealed that the minority of parents had accessed relevant supports (Cameron et al., 2020) Thus, scarce data exist to help tailor services to address the needs and barriers to care experienced by parents during the pandemic.
The purpose of this descriptive study was to characterize parental distress, psychological support, and service preferences during the COVID-19 pandemic to generate hypotheses for future studies and guide the expansion of services in our psychotherapy clinic. Given caregivers continue to face the cumulative and ongoing effects of the pandemic, we believe these data can help inform larger scale efforts to understand support needs and adjust clinical services accordingly to help address the perinatal mental health crisis (Osborne et al., 2021).

Participants
Participants (N ¼ 95) were recruited through the local community between March 2021 and June 2021. Eligible participants self-identified as pregnant (n ¼ 8), postpartum (n ¼ 9), a partner of a pregnant/postpartum person (n ¼ 1), and/or a parent of a minor (n ¼ 76). Ninety-four individuals consented to participate. Seven were excluded due to insufficient data, thus the final sample size was 87. Enrolled participants completed a secure online survey in Qualtrics. Following study completion, participants were entered in a drawing for a $50 gift card and provided with mental health resources.

Data analytic plan
Analyses were conducted in R, version 3.6.3 (Core Team, 2017). Descriptive statistics were computed for demographics, clinical data, and qualitative responses. A one-way ANOVA with Tukey's HSD was used to compare TAFQ scores across services.
A wide range of psychological distress severity scores was observed (see Table 1). Average scores across IDAS-II subscales (e.g., dysphoria, insomnia) appeared lower than those observed in pre-pandemic adult and postpartum samples (Watson et al., 2007). Still, 34.9% of respondents were above the screening cutoff for internalizing disorders (Dysphoria >19.50; Stasik-O'Brien et al., 2019), and 42.0% reported well-being scores more than 1SD below the validation sample.

Treatment acceptability
Participants (n ¼ 59) next completed the TAFQ after reviewing psychoeducational information on common support services offered in outpatient clinics (e.g., individual or group therapy, medication, telehealth). Individual therapy (M ¼ 25.59, SD ¼ 3.94) and telehealth (M ¼ 25.11, SD ¼ 4.75) were widely accepted (see Fig. 1). Group therapy (M ¼ 18.20, SD ¼ 4.88) and medication (M ¼ 20.53, SD ¼ 6.43), by comparison, appearing less acceptable. TAFQ for group therapy ranged widely. A one-way ANOVA supported that there were significant differences in TAFQ scores across services (F 3,229 ¼ 26.85, p < .05), with post-hoc comparisons revealing individual therapy was reported as more acceptable than both group therapy and medication (p's < 0.001), consistent with individual preferences reported above.

Discussion
The majority of our sample (72%) indicated a mental health concern for which they were interested in receiving support. Distress related to parenting, stress, anxiety, and depression were prevalent and high priority concerns. Parents reported particular interest in individual therapy, mind-body or parenting classes, parenting classes, and virtual services, and both individual therapy and telehealth were rated as widely acceptable and feasible. These findings extend the literature by indicating prevalent, specific interests in support services among caregivers during the pandemic.
Notably, very low interest was observed for group therapy, even after participants received educational informational on its benefits (e.g., costeffective, opportunity for social connection and support). This finding warrants attention, given the cost-effectiveness and efficacy of group interventions for common perinatal mental health concerns, such as anxiety and depression (Coto-Lesmes et al., 2020;Muzik et al., 2015). Still, parents appeared willing to engage in "classes" targeting high-priority areas of concerns (e.g., stress, parenting). Thus, clinicians may need to consider the format and presentation of group-based services; evidence-based, "skills classes" may be viewed as more acceptable and feasible. Further examination to identify moderators of the acceptability of group therapy is warranted (e.g., fears of judgment, perceived ineffectiveness) to inform effective psychoeducation and service adaptation, and in turn, help improve access to care.
Of note, despite the overall high socioeconomic status of the sample, 65% of participants indicated barriers to care related to finances and 60% indicated barriers related to childcare. Many logistical barriers were also reported (e.g., availability, clinic hours). Critically, these barriers are likely exacerbated in underserved communities (Walker et al., 2015). Further consideration of treatment acceptability and barrier to care is critical to ensure equitable access to care. Policy and healthcare initiatives to facilitate affordable services and childcare support may aid in addressing these barriers.
This study, while contributing novel information regarding caregiver healthcare preferences amidst the pandemic, has a number of limitations. First, we relied on a small convenience sample, which was limited in its demographic diversity (i.e., majority White, cis-gender female, heterosexual, partnered). The pandemic has had disproportionate effects on marginalized and underserved communities (Feinberg et al., 2021), which may bear important implications for the support needs of impacted caregivers. Moreover, cultural factors are known to influence treatment preferences and intervention acceptability, and such mediating factors could not be examined within the scope of our study. Promoting inclusion through study procedures (Williams et al., 2013) is critical to increasing representation in research, and improving access to culturally responsive services for underserved caregivers. In addition, our Fig. 1. Boxplot of acceptability and feasibility scores for psychological support services among parents in the sample. Note. TAFQ ¼ Treatment Acceptability and Feasibility Questionnaire (range ¼ 0-30, with higher scores indicating higher levels of acceptability and feasibility for the given treatment modality). sample was not sufficiently powered to examine whether findings differed across by pregnancy, postpartum, or parental status. Future research is needed to evaluate how mental health needs differ across groups. For example, parents of younger children (e.g., toddlers) may have experienced greater distress due to caregiving demands, compared to parents of adolescents who were more autonomous. Finally, our data represent a snapshot in a developing crisis; continued assessment is warranted as the virus, and its impacts, continue to evolve.
Pandemic stressors are ongoing for caregivers of young children. Providers and researchers need to respond to evolving mental health needs among expecting and current parents with feasible and efficacious interventions. Clinicians may be able to mitigate barriers to care by offering telehealth services, skills classes, childcare resources, reduced fee options, and advocating for additional insurance coverage. Researchers can support caregivers by investigating the specific needs of diverse populations as they navigate pregnancy, postpartum, and parenthood in the pandemic. Given the present mental health crisis in caregivers, addressing these gaps may help increase access to vital supports.

Ethics standards
The study and all relevant procedures were approved by the local ethics committees (University of North Carolina at Chapel Hill). All procedures were conducted in compliance with institutional ethics standards and APA guidelines for the conduct of human subjects' research.
Contributors SNH, TAH, and CES contributed to the conceptualization of the study. Data cleaning, formal analysis, and interpretation were performed by SNH, LL, and CES. The initial draft of the manuscript was written by SNH, LL, KT, MK, TM, and TAH. All authors contributed to manuscript editing and approved the final manuscript for publication.

Declaration of competing interest
None to declare