Abstract
The growth of the Internet and its projected effects in the next decade will have implications for the practice of all forms of medicine, including psychiatry [1,2]. Perhaps more importantly, the growth of the Internet has enormous potential for facilitating the development of mental health literacy in the community and for providing mental health programs accessible to many who do not seek or cannot access professional treatment. In the area of health and mental health, websites are very popular, with sites such as the Mental Health Net [3] reporting 400 000 hits per month [Dombeck M: personal communication].
The qualities that have led to the explosion of the Internet in the last 10 years have been: (i) its accessibility from multiple geographical sites at all times of the day (hence its convenience and its global reach); (ii) the opportunity it provides for rapid dissemination of information; (iii) the ability of the site author to quickly update information at little cost; (iv) its attractive format, capacity for interactivity and potential for multimedia presentation; and (v) the range of information available. These qualities can lead to negative outcomes through, for example, the fast dissemination of inaccurate information.
In this paper, we explore the possible roles of the WWW in clinical practice, in the promotion of mental health and in the prevention of mental health disorders. We identify a number of areas where the WWW has potential for promoting clinical practice and mental health literacy. We also identify areas of potential disadvantage and danger of the new technology.
We take two perspectives: (i) the impact of the Web from the point of view of the practising/researching psychiatrist/mental health professional (the practitioner view) and (ii) the impact of the Web on the public's knowledge of mental health (mental health literacy; the community view or public health view). These two perspectives are not independent, but provide a useful platform to examine the issues. These perspectives are applied to two areas of impact: (i) knowledge and information and (ii) treatment and self-help.
Knowledge and information
The practitioner view
The WWW provides information that might serve a number of purposes for the psychiatrist or mental health professional in clinical practice. First, information of use to the practitioner's clinical work and continuing education is available. This includes immediate access to information about drugs, side-effects and therapies; to journal articles, books, recent newspaper reports; and professional sites. Information is available about clinical practice guidelines and the effectiveness of interventions from sources such as the Cochrane collaboration. The Internet may also be used for meetings or virtual conferences.
Second, information that might be used to facilitate patient management and education is also available on the Internet. Clinicians may develop a portfolio of useful sites that provide information they consider of value for their patients. They may, for example, refer patients or their families to sites about depression. Clinicians with their own sites might post specific information for their patients (and the patient's relatives) about doses, side-effects, further referral, after hours assistance and other topics relevant to the patient's management and recovery.
The community view
From the community health perspective, a wide range and quality of mental health information is available for use by consumers on the WWW [4,5] including extensive sites such as Internet Mental Health [6] and Mental Health Infosource [7]. First, potentially, such information may inform the public about the nature and effective treatment of mental health disorders. An increasing number of Australians regularly access the Internet. For example, approximately 75% of all 18–24-year-olds in Australia accessed the Internet in the 12-month period prior to May 1999, compared with 49% in the previous year [8]. The resulting increased access to mental health information will produce more informed patients, resulting in a change in the knowledge relationship between patient and doctor. Perhaps more importantly, people with symptoms or needs who do not seek professional help may nevertheless access information about mental health on the WWW. This is important since it has been estimated that only a minority of people with mental disorders in the community seek professional help [9].
Second, the WWW is also a potentially useful medium for educating practitioners and public health organisations about consumers' views of the appropriate treatment for psychiatric illness and consumer perceptions of the limitations of current treatments. Although information on websites is not necessarily representative of community views, mental health problems are often unrecognised and consumers' beliefs about treatment suitability may be important in selecting the most effective treatment or prevention for them [10].
In short, information on the WWW has the potential to inform psychiatrists, educate patients (or carers) about treatment, assist the community in identifying common mental disorders and potentially useful treatments and inform the medical profession and the public health community about the views of consumers.
However, there are potential problems arising from the availability of this information. Yellowlees and Brooks [2] have identified these as information overload and information quality. Information overload is a major problem. Internet programming experts have estimated that it would take approximately 50 000 person-years to read all the pages of the Internet [Hawking D: personal communication]. Meanwhile, the number of sites continues to proliferate and these may be huge or poorly organised making it difficult to find relevant information.
Search engines have been developed to retrieve information from the Web and reduce the number of pages presented as potentially useful to the user (see Hawking et al. for a review of search engine effectiveness [11]). However, even the best of these search engines lack retrieval precision. One response to this problem is to develop portal websites dedicated to health, mental health or a particular mental health issue. These sites usually consist of a collection of specific content, indexed, and a local search engine together with links to other recommended sites. The usefulness of such portals still depends on the sites referenced and the quality of the attached search engine. Future portals will no doubt provide subject-focused searches over a wide range of external sites, but a number of technical and legal problems need to be solved to achieve comprehensive high-quality coverage.
The second issue concerns the quality of information on the Internet. One major concern is that consumers (and practitioners) will obtain inaccurate or potentially dangerous information [12,13]. The egalitarian nature of the Internet allows any individual to post a site. There are many examples of poor sites promising untested treatments for depression [5]. A number of evaluation criteria have been proposed [14]. The most frequently used are the accountability criteria of Silberg, Lundberg and Musacchio [15] which require the user to check the site's characteristics including when it was last updated, authorship details, attribution of sources and disclosure of ownership. However, there is no published evidence that these criteria are indicators of the quality of the content of sites. Validation requires the comparison of Silberg et al. scores with a ‘gold standard’. The latter would be based on consistency with the scientific evidence or the standard clinical practice guidelines. Internet sites devoted to physical health have been found to be of poor quality and to contain important omissions [11,16]. Nevertheless, the problem of quality may be solvable. It may be possible in the future to develop intelligent search engines that operate using algorithms validated by reference to the ‘gold standard’.
We have recently audited 21 popular websites on depression [12] and found that the quality of such sites is poor, that they lack balance, and that they do not provide treatment information consistent with the ‘gold standard’. They also include misinformation or information that could be easily misinterpreted. For example, one site, written by a psychiatrist, provided information on the means by which consumers could identify whether their doctor was an ‘expert’ in the treatment of depression. One criterion for the identification of this expertise was the use of the combination of monoamine oxidase inhibitors with tricyclic antidepressants! However, despite the potential for disseminating misinformation, many sites resemble the curate's egg in that they are good in parts. Consumer sites, for example, offer the potential to educate mental health professionals about the issues that are of major concern to consumers. In our review, we were struck by the frequency with which unwanted and painful side-effects of medication were discussed and with which advice was offered about selecting a good therapist. This suggests further research into side-effects is warranted and that counselling about side-effects is essential for compliance.
Treatment or treatment supplementation and self-help
The practitioner view
From the perspective of the clinical practitioner, the Web may provide a forum for mental health diagnosis, therapy, management and support. Examples within medical practice include the use of Internet-assisted diagnostic instruments and the use of case-conferencing facilities to link patients with other specialists or mental health professionals. As an adjunct to treatment, psychiatrists might also recommend chat groups as a means of social support for isolated patients, albeit that there may be some dangers in these groups if the patient is left unsupported (see below).
The community view
More controversial is the use of the WWW as a means of self-help, and this use has public health implications. For example, for depression, individual online therapy is available for those with access to sites and financial resources. A popular site is Cyberpsychologist [17], which provides an online self-help service. The website www.metanoia.org [18] lists over 160 therapists who provide online counselling including many who provide ongoing contact by means of email or chat sessions. Computer-assisted therapy programs for depression can be purchased, downloaded and used at home [19]. Information is available about purchasing and making correct dose antidepressants using St John's Wort and a variety of other herbs and potions including kava, coffee, gingko, vitamins, tryptophan and many others. A range of self-help lifestyle changes are documented to help depression including activity scheduling, music, massage, prayer, subliminal tapes and colour therapy. Self-diagnosis using a range of validated and non-validated anxiety and depression scales can be readily accessed. If chat groups, monitored by a professional chat group host can be regarded as group therapy, this already exists at multiple sites. Specific inquiries about problems of young people can be answered at Go Ask Alice [20]. The actual behaviour of ‘surfing the Net’ may also be seen to be a form of occupational therapy, and of potential benefit. The sociocultural implications of bringing people together have yet to be explored, but this new ‘connectedness’ may contribute to social capital and promote mental wellbeing.
There are public health implications of the availability of these services on the Internet. The first problem is the potential harm that might arise from these activities. There is little concern about the use of Web services as an adjunct to treatment or source of discussion in a clinical setting. However, online therapy, alternative treatments, self-diagnosis and chat groups have been claimed to be harmful or even dangerous [21]. Online therapy may be of poor quality, inappropriate, conducted by untrained practitioners, use insecure message systems which violate patient privacy and produce dramatic negative effects. Self-diagnosis feedback could lead to great anxiety. Chat groups, where comments reign unchecked by either host or other participants may be extremely distressing. Cyberstalking has recently been reported [22].
The second related problem is the lack of evidence about the effectiveness or otherwise of these services. To our knowledge, none of these site activities have been appropriately evaluated. There is some evidence from uncontrolled trials that suggests Internet use in general may decrease social interaction and increase loneliness [23,24]. The validity of self-assessment instruments administered via the Internet has been reported [25]. However, the effectiveness of online therapy activities has not been evaluated systematically. Over 90% of a sample of more than 400 online counselling clients reported in a survey that Internet therapy assisted them [26]. However, the survey would appear to have been conducted on a self-selected sample, with no control group and limited outcome measures.
Nevertheless, it is highly probable that interventions using the Internet will be found to be effective. There is evidence that self-help using non-Internet resources can work. Bibliotherapy is reported to be highly effective in the treatment of depression [27]. Computerised therapy has also been found to be an effective medium [28] and may translate easily to the Internet. It is possible that interactive, multimedia sites using proven therapies and developed using an educational format may be as effective or more effective than other self-help mediums. These programs have the potential to be accessed by those who would not normally seek professional help or those in rural areas, for example, where access to psychiatrists or psychologists is not possible. Moreover, it will be possible to track user behaviour on the sites, to determine the most ‘attractive’ features of the packages. While use of the Internet is associated currently with higher education, it has the potential to decrease social inequalities as it becomes ubiquitous.
Conclusions and future directions
Issues of overload and quality of information, the potential for harm and the need to evaluate interventions are not unique to the Internet. For, example, it has been reported that four million articles are added to the biomedical literature each year [29]. However, the features of the Internet which exacerbate these problems are its immediate accessibility and capacity for fast dissemination.
The Internet is likely to facilitate access to information, to increase mental health literacy and to provide a broader range of information for those outside the medical sphere. Those who do not traditionally seek medical help may be helped and those with early symptoms may reach help earlier. Knowledge and treatment via the Internet may decrease unmet need. More specifically, the likely effects of the Internet on the psychiatrist's role would be that such therapy and information, if available and of good quality, could be harnessed for use as an adjunct to therapy. The increase in mental health literacy might lead to additional consultations for psychiatrists and other professionals. Our recent audit of depression sites found that all 21 sites recommended that depressed people seek the help of a health professional [5].
What is most clear is the research agenda. A program to evaluate Internet-based mental health information with respect to what is known scientifically is highly desirable. There is a need to establish whether search engines can be developed which assess the quality of website information. The possibility of attempting to establish packages of ‘therapy’ on the Internet is exciting, although the potential dangers of such interventions need to be addressed simultaneously. Finally, there is a clear need to evaluate Internet interventions systematically, albeit that what is being evaluated is likely to be a movable feast.