Information resources

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

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

Professional practice

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.

Future trends

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.