The internet and mental health practice
The internet is one of the fastest growing technologies in the world. The number of web users worldwide is estimated at 513 million,1 with approximately 100 million adult users in the United States2 and 25 million in the United Kingdom.3 There is evidence that seeking health information is one of the most common reasons for using the internet.4 About 100,000 websites dedicated to health information have been identified.5
As in other areas of medicine and clinical practice, the internet and its associated technologies have begun to change the nature of mental health practice. Moreover, because the internet facilitates access to information and resources by patients and clinicians, there is an increasingly “mental health literate” community who may seek certain types of web-based mental health interventions. Self help is of increasing importance in Western countries. For instance, about 4% of the American population may undertake self help for medical conditions in any 12 month period.6 The internet provides fee and non-fee-based professional therapy, counselling and self help packages directly to the community.
In this EBMH Notebook, we update a previous paper on the expanding role of the internet in mental health practice.7 We consider the internet from the perspective of the mental health specialist, examining its impact in two domains: (a) information resources and (b) treatment provision. We discuss the scope of information and treatment resources for the practitioner and provide examples of resources. We also discuss the advantages and major obstacles to using these technologies. Finally, we speculate about the ways in which the internet will continue to change clinical practice and likely future trends.
Resources available for practitioners
There are a number of well known sites which provide starting points to find mental health resources on the internet (see table). Professional resources include immediate access to information about clinical management, medication use and research through the online publishing of clinical journals, books, news articles, clinical practice guidelines, and government regulations. The internet supports sophisticated search engines which locate information readily, and allow searches of research databases (such as PubMed).8 Professional information is disseminated by online forums, newsgroups and internet tutorials, with many professional organisations communicating and conferencing via the web. Business assistance, accounting, career information and proscribing software can be readily obtained.
Clinical tools are also available online. Practitioners may wish to subscribe to or use online assessment tools. Although validation, standardisation and copyright violation may be potential disadvantages of these resources, the advantages are ease of testing from many locations and immediate scoring and assessment.9
The internet also provides information that might facilitate patient management or education. This includes hundreds of web sites providing patient education. The practitioner may develop a useful portfolio of useful high quality sites, or produce his/her own website to disseminate relevant clinical and personal information. The DMOZ directory provides a catalogue of professional resources including academic programmes, associations, continuing education, internet psychology resources and publications.10
Obstacles and disadvantages
Two major issues when using the web for information are too much information and no quality control.11 Wading through huge amounts of uncensored information of low quality is time consuming and frustrating. Focused search engines or edited portal sites maintained by professional societies, professional librarians or other organisations may help to reduce to volume of information retrieved.
Quality is a greater challenge.12 There has been intense international interest in this issue fuelled by anxieties about patient harm,13 but some believe that medical information on the internet should not and cannot be regulated. For professionals, a major issue is recommending sites whose content is evidence-based. Good quality psychological and psychiatric health information may improve treatment adherence. False, explicit or harmful information may have devastating consequences (“copy cat” suicides, for example). A recent review examined three major initiatives to tackle quality issues: codes of conduct or ethics (self regulation through adherence to a code of conduct); third-party certification, and tool-based evaluation.14 Each of these initiatives had disadvantages, including the burden placed on health information producers, users and certifiers; the need to maintain initiatives; user indifference; and the absence of meaningful enforcement mechanisms.
In the field of mental health, indicators of the quality of information on websites are yet to be determined. Recent research suggests a correlation between web quality as assessed by clinical practice guidelines and site features such as DISCERN ratings and the presence of an editorial board.15–17 Site popularity is not sufficient. The correlation between quality and Google Page Rank, a measure of site inter-connectiveness, has not been established. 18
In the United Kingdom, there are efforts to provide evidence-based mental health material as part of the National Electronic Library for Health.19 Nevertheless, quality of information remains an issue, particularly for consumers who do not necessarily have the training or the professional context to assess the validity of information or key indicators of quality.
There has been a lack of evaluation of the effects of internet information on professional services and consumer mental health knowledge. Web information is used increasingly by psychologists and professionals from related professions.20 While this suggests that the internet is a useful medium for information dissemination, it remains unclear whether the internet can foster good clinical practice or improve mental health outcomes. Moreover, there is no evidence that providing high quality web based information to people with mental health problems improves patient outcomes or mental health literacy.21
Treatment services on the internet
A range of different types of mental health services or “interactions” are available through the internet (see table).22–23 Web-based interactions can be classified in a number of ways according to the intervention type (for example, assessment, early intervention, relapse prevention); the type of relationship (consumer / professional; consumer / consumer; professional / professional); or the purpose of the site (interventions developed by mental health professionals for patients, interventions that encourage self help management of symptoms, and sites designed to provide emotional support).
There are numerous examples of different types of mental health sites. For instance, some sites provide email contact or a bulletin board for advice and referral;24 counselling by email;25 real time counselling through chat technology, web telephony and videoconferencing (telepsychiatry); community treatment programmes operating via email26 and web training, bibliotherapy through downloadable self help guides, and fee-based and free health communication systems delivering tailored treatment. 27–29 Support groups are proliferating on the internet, and these groups may provide an alternative to conventional face to face therapy.30
The advantages of internet-mediated therapy and support include greater access to remote and rural areas, reduced cost and ease of communication. Patients report that online discussion of problems is easier and allows them to discuss issues they feel unable to raise in a face to face interaction. The internet provides a service for those who are dissatisfied with traditional intervention methods for various reasons, including stigma.31
Disadvantages include few training schemes and the lack of developed standards, despite initiatives to address ethical guidelines.32–33 Some believe that internet therapy may encourage voyeurism and dependency and encourage a “digital divide” due to inequitable access.34 There are two other major obstacles in the development of online therapy: (a) a lack of evidence of the effectiveness of internet interventions and (b) the inadequate pace at which professional organisations are responding to online therapy.
Evidence of effectiveness
There are a number of internet interventions for treating anxiety or depression, including COPE, FearFighter, and the Therapeutic Learning Program.35–37 There have been few studies on the effect of these types of interventions, although evidence is beginning to emerge that the internet can be used to deliver cognitive behaviour therapy designed to prevent depression.37 The internet has also been used to modify eating disorders and prevent obesity through exercise.38–39 Internet delivery may be as effective as classroom delivery for these interventions,41 although a recent randomised trial did not find any effect from an internet-based cognitive behaviour programme.42 There is clearly a need for further research.
Further randomised controlled trials of internet technologies are needed to convince clinicians and policy makers of their effectiveness, feasibility and economic value. It is also imperative to understand how consumers use and interact with e-mental health services. Finally, there is a need to investigate the usefulness of professionally mediated online support groups. Evidence to date suggests that face to face professionally mediated support groups are popular, may be effective, and are used by proportionally more individuals with stigmatising disorders, such as depression, than individuals with less stigmatising disorders.40–41 It has been suggested that online interactions have unique benefits.43
There is evidence that patients may prefer online help in some instances, yet professional societies may not be responding fast enough to the demand for online services. A recent survey of participants in Norwegian online mental health discussion forums found that the majority of respondents preferred that active participation in these groups by professionals.43 The authors concluded that “Professionals will need new knowledge and perceptions of their roles, and public authorities will have to decide their role in influencing the quality of services offered, and the social values conveyed, to those who seek help through the internet” (p 59). E-mail counselling was also reportedly more popular than face to face or telephone counselling for mental health problems in a recent Japanese survey.31
There may be an unmet need for help, with many unable to access services because of expense or lack of accredited counsellors. Online services have the potential to address some of this unmet need. Yet there are also dangers. Practitioners in clinical practice may respond to emails from patients without considering the associated legal and ethical issues. Given these factors, there is a need for professional societies to develop standards and accredited training to help protect practitioners and assist consumers in online counselling.
It is difficult to predict future trends, especially in areas where technologies are rapidly developing. In 1943, the Chairman of IBM suggested that “there is a world market for maybe five computers.”44
Despite the difficulties with prediction, we believe that there will be a rapid expansion of current internet services, including more online professional communication, publishing, training, counselling and online information. Although web counselling may account for considerably less volume of interaction than telephone counselling at present, this is likely to change because more people are beginning to routinely access health information online. At the level of professional practice, it is likely that mental health practitioners will be more informed about online interactions of all types, use them with a more complete understanding of their implications, use and provide patient information electronically to other professionals, (possibly) employ online counsellors as locums and offer more services to those in remote and rural areas. If found to be cost effective and beneficial, consumers and the Government may demand more widely available internet services.
The question remains whether internet technologies can be used to create novel mental health interventions, thereby changing the nature of mental health practice, or whether these technologies provide opportunities to complement already existing practices through their use as adjunct treatments. It is difficult to judge what is truly innovative and unique and what is an extension of existing practices using alternative media. To us, it would seem that internet technologies will both complement and expand existing services. Given the huge appeal of the internet and its capacity for tailored information dissemination, it may radically change how health care can be delivered to the community. The internet creates new networks and partnerships and it provides a unique opportunity for confidential access to a broad range of services and treatment options. For example, the internet allows us to provide services to individuals who do not have access to or do not wish to access general practice services, because these services are not tuned to their needs, because of distance or perhaps because of the stigma they feel. Providing such services through the internet may fulfil goals that were not previously considered a possibility in mental health practice. Ultimately, it may be possible to provide health care services which do not require the assistance of a human operator at any point. Whether this is desirable is highly debatable, but such assistance would certainly to be regarded as a radical change in the provision of mental health services.
Funding for this study was provided by NHMRC Programme Grant 179805. This article updates a previously published paper: Christensen H, Griffiths K. The internet and mental health literacy.