title: Using vignettes to assess contributions to the work of addressing child mental health problems in primary care.
abstract: BACKGROUND
  To further efforts to integrate mental health and primary care, this study develops a novel approach to quantifying the amount and sources of work involved in shifting care for common mental health problems to pediatric primary care providers.
  
  
  METHODS
  Email/web-based survey of a convenience sample (n = 58) of Maryland pediatricians (77% female, 58% at their site 10 or more years; 44% in private practice, 52 % urban, 48 % practicing with a co-located mental health provider). Participants were asked to review 11 vignettes, which described primary care management of child/youth mental health problems, and rate them on an integer-based ordinal scale for the overall amount of work involved compared to a 12th reference vignette describing an uncomplicated case of ADHD. Respondents were also asked to indicate factors (time, effort, stress) accounting for their ratings. Vignettes presented combinations of three diagnoses (ADHD, anxiety, and depression) and three factors (medical co-morbidity, psychiatric co-morbidity, and difficult families) reported to complicate mental health care. The reference case was pre-assigned a work value of 2. Estimates of the relationship of diagnosis and complicating factors with workload were obtained using linear regression, with random effects at the respondent level.
  
  
  RESULTS
  The 58 pediatricians gave 593 vignette responses. Depression was associated with a 1.09 unit (about 50%) increase in work (95% CL .94, 1.25), while anxiety did not differ significantly from the reference case of uncomplicated ADHD (p = .28). Although all three complicating factors increased work ratings compared with the reference case, family complexity and psychiatric co-morbidity did so the most (.87 and 1.07 units, respectively, P < .001) while medical co-morbidity increased it the least (.44 units, p < .001). Factors most strongly associated with increased overall work were physician time, physician mental effort, and stress; those least strongly associated were staff time, physician physical effort, and malpractice risk. Pediatricians working with co-located mental health providers gave higher work ratings than did those without co-located staff.
  
  
  CONCLUSIONS
  Both diagnosis and cross-diagnosis complicating factors contribute to the work involved in providing mental health services in primary care. Vignette studies may facilitate understanding which mental health services can be most readily incorporated into primary care as it is presently structured and help guide the design of training programs and other implementation strategies.
authors.affiliation: Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, 703 Hampton House, 624 N. Broadway, Baltimore, MD, USA. lwissow@jhmi.edu.
authors.forename: Lawrence S
authors.initials: LS
authors.lastname: Wissow
authors.affiliation: Department of Emergency Medicine, World Health Organization Collaborating Center for Emergency Medicine and Trauma Care, Aga Khan University, Karachi, Pakistan. waleed.zafar@aku.edu.
authors.forename: Waleed
authors.initials: W
authors.lastname: Zafar
authors.affiliation: Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, 703 Hampton House, 624 N. Broadway, Baltimore, MD, USA. katefothergill64@gmail.com.
authors.forename: Kate
authors.initials: K
authors.lastname: Fothergill
authors.affiliation: Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA. aruble@jhmi.edu.
authors.forename: Anne
authors.initials: A
authors.lastname: Ruble
authors.affiliation: Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA. Eslade@psych.umaryland.edu.
authors.forename: Eric
authors.initials: E
authors.lastname: Slade
mesh_terms: D000293:Adolescent; D001008:Anxiety Disorders / Q000628:therapy*; D001289:Attention Deficit Disorder with Hyperactivity / Q000628:therapy*; D002648:Child; D003866:Depressive Disorder / Q000628:therapy*; D005260:Female; D006801:Humans; D008396:Maryland; D008605:Mental Health Services / Q000458:organization & administration; D010372:Pediatrics; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care / Q000458:organization & administration; D011795:Surveys and Questionnaires; D000069341:Transitional Care / Q000706:statistics & numerical data; D016526:Workload / Q000706:statistics & numerical data