Computers and the Internet have rapidly become a common fixture of modern life. According to a recent report by the US Department of Commerce1 more than half of the nation is now online, with a rate of growth of approximately two million new users each month. Internet use is increasing for people regardless of income, education, age, race, ethnicity, or gender. In the last several years, Internet use by individuals in the lowest income households (those earning less than $15,000 per year) increased at a 25% annual growth rate.
Americans are going online to conduct an expanding range of activities. Forty-five percent of the population now use e-mail, up from 35% in 2000.1 One of the most frequent uses of the Internet is to obtain health information. A recent Pew Foundation report on Online Communities2 found that 84% of American Internet users have sought health information from an online health group. Ninety-one percent of health information seekers have looked for material related to a physical illness, while 26% have looked for mental health information.
Although the Internet will continue to serve as a major source of information, its potential for providing mental health services is largely untapped. The Internet is particularly well suited to provide structured interventions and self-help groups and to reach large populations. As such, it has the potential to facilitate evidence-based medicine that emphasizes standardized, outcome-oriented, algorithm-driven interventions. Evidence-based treatment guidelines have become the standard of practice in many settings.3'4
New psychosocial interventions, derived from social learning theory and cognitive-behavior therapy, including relapse prevention, motivational interviewing, and the transtheoretical model of behavior change, are philosophically and practically applicable to evidence-based medicine and are often developed in such a way as to allow rapid translation to the Internet.
The Internet also has the potential to improve communication among patients and providers. A number of studies have shown that patients are often dissatisfied with their provider interaction, frequently because of inadequate or poor communication. Semantic and syntactic difficulties, specialized terms, complex sentences, and the absence of an affective mutual understanding contribute to problematic communication. Considering that the average patient visit in primary care is about 15 minutes, the time, frequency, and quality of patient and physician contact can be augmented or improved with electronic communication. Most important, electronic communication can be structured to determine how well information is understood and accepted and even to help assess the patient's level of satisfaction with the communication.
Changes in the ways patients view their role in their own health (from physician-directed to selfmanagement) also appear to be occurring and are relevant to the Internet. Patients can now obtain medical information about problems and treatments, including nontraditional ones, easily.5 This cultural change may improve health care. Wagner et al.6 provide evidence that self-management patient-physician partnerships are associated with better outcomes.
WHY USE THE INTERNET?
As discussed above, patients are already accessing the Internet for medical information. The National Institute of Mental Health reports that approximately 7 million hits are registered every month on its home page.7 E-mails from patients to their providers have become much more common and some patients now expect this from their physicians.89
The Internet provides accessibility to health care information and programs for a number of individuals who may have economic, transportation, or other restrictions limiting access to face-to-face health care. The Internet is available at all times and can be accessed from a variety of places.
The Internet has the potential to include many individuals otherwise left out of health care interactions. Because text and other information on the Internet can be presented in a variety of formats, languages, education levels, and styles, it is possible to tailor messages to the learning preferences and strengths of the user.
The greatest benefit of the Internet will probably be in communication and coordination. Although physicians have been reluctant to use e-mail, this will undoubtedly change as patients demand it. Many of the current telehealth programs (telephone directed, home-based, structured programs) include processes that can easily be put on the Internet - messages and conversations among providers (eg, telemedicine treatment for depression).10 Integrated systems save time for patients and providers and improve care; some health maintenance organization patients can easily order prescription refills online, check the status of their prescriptions, and indicate whether they would like to pick up the refills or have them mailed to their home.
The Internet can facilitate the collection, coordination, dissemination, and interpretation of data. Already a number of programs have been developed to collect physiological, biological, and self-reported data online. Such data, once collected, can be graphed, stored, or analyzed in any number of ways on individual (eg, monitoring progress) or system levels (eg, determining how well practitioners follow guidelines /algorithms and achieve outcome goals).
All of these features allow for interactivity among physicians, patients, family members, and caregivers and functions of providing health care.
As data transmission time is reduced and high bandwidth networks become standard, truly exciting and interesting programs relevant to the patient can be immediately available on the Internet. However, despite this potential, analyses of Web site information has found that information is written for better educated populations,11 is often misleading, inadequate or incorrect,12"15 or is used to attract customers to products related to a health topic. A few sites use modern learning theory principles to most effectively educate patients. Meta-analyses of computerassisted instruction have consistently found it effective,15 yet educational Web sites often fail to adhere to solid pedagogical principles.16
As guidelines, information, and other aspects of programs change, it is possible to update information on Web pages rapidly. The medium also allows for personalization of information. Users may select aspects, features, and information most relevant to them and, conversely, programs can automatically determine a user's needs and strengths and provide programs accordingly.
THE USE OF THE INTERNET FOR MENTAL HEALTH INTERVENTIONS
The numbers, types, and target audiences of Internet mental health programs are exploding. Several journals are devoted to issues related to computer and telephone-based intervention (eg, CyberPsychology & Behavior, Journal of Medical Internet Research, Journal of Telemedicine and Telecare). In addition, a number of books have been published related to mental health practice and the Internet, and there is also a society for online counselors. Unfortunately, research on issues related to this technology for mental health practice is in its infancy. In the following section, we highlight some of the directions.
The widest use of the Internet for mental health is undoubtedly for information. However, the quality of this information is often inaccurate, misleading, and /or related to commercial interests. In a review of 178 active sites about depression, Lissman and Boehnlein,14 found that only half of the sites adequately described depressive symptoms, including diagnostic criteria or symptoms of depression. Almost half of the sites made no mention of medications, psychotherapy, or professional consultation as suggested treatments for depression. Nonprofit-sponsored sites provided better and more balanced information, but search engines often list for-profit sites before nonprofit sites.
Serving and Assessment
A number of information-based Web sites now provide screening programs that patients can use to determine if they are at risk or have signs or symptoms requiring follow-up. The National Institute of Mental Health and many other professional organizations provide high-quality, easily accessible information combined with screens. For example, Houston et al.17 looked at the use of a Web site that offered the Center for Epidemiological Studies Depression Scale. The scale was completed 24 479 times during the 8month study period. The respondents' median age was 30 to 45 years, 70% were women, 58% screened positive for depression, and fewer than half of those had never been treated for depression. The Internet can incorporate interactive screening that has already been extensively developed for desktop computers.18 Interactive screens also solve the problem of balancing sensitivity and specificity in problems with low-prevalence. Because of the costs of screening, the conventional wisdom is to maximize sensitivity and specificity.19 However, with an interactive screen, it is possible to have a first-level screen with high sensitivity but low specificity (most potential cases are captured but many false-positives also identified) followed by another screen with higher specificity that can then screen out for false-positives. Screening can then be linked to strategies (eg, motivational interviewing) to enhance acceptance of referral for treatment if appropriate.20
Online Support Groups
Because Internet-delivered group interventions can be accessed by participants at any time from any location with Internet access, they offer some distinct advantages compared to their face-to-face counterparts. Face-to-face support groups are often difficult to schedule, meet at limited times and locations, are resource-intensive (eg, staff), and must accommodate inconsistent attendance patterns because of variations in participants' health status. In particular, online groups help rural residents or people with long-term illnesses or disabilities increase their access to these interventions.
A wide array of social support groups are available to consumers in either synchronous or asynchronous formats.21 The Pew Internet and American Life Project2 estimated that 28% of Internet users have attended an online support group for a medical condition or personal problem. Following a morning television show that featured Edward M. Kennedy, Jr., discussing the availability of free online support groups provided by the Wellness Community (www.wellnesscommunity.org), that organization received more than 440 000 inquiries about their services over the following week. The majority of published studies on Internet-based support suggests that the groups are beneficial, although scientific understanding of how and when these interventions are beneficial is limited. Studies of the patterns of discourse that occur in these groups indicate that members communicate in ways that are characterìstic of face-to-face communication (eg, with high levels of mutual support, acceptance, and positive feelings).12'21
Online consultation with expert advice is readily available on the Internet. There is even an organization for online therapists. However, very little is known about the efficacy, reach, utility, or other aspects of this activity. A more important use of the Internet will be to combine face-to-face interventions and online and telemedicine programs. There is substantial evidence for the benefit of such structured care management programs for depression and other problems.22
The Internet has become an important medium for advocacy and other political issues. Many organizations use the Internet to facilitate communication among members and to encourage members to support issues.
The Internet facilitates the combining of components for interactive programs. The basic components of interactive programs can be considered to include information, psychoeducation, support and chat groups, monitoring and feedback, and provider interactions tied to algorithms, treatment guidelines and outcomes. Many programs developed for desktop computers are readily translatable to the Internet, although surprisingly few have been translated to the Internet and evaluated.23' 24 Klein and Richards25 found that a brief Internet-based treatment was effective for reducing symptoms in patients with panic disorder. Carlbring et al.26 randomized 41 individuals with panic disorder to an Internet program that included psychoeducation, breathing retraining, cognitive restructuring, interoceptive and in vivo exposure, and relapse prevention, or a waitlist control. At follow-up, patients using the Internet program did significantly better than the waitlist controls. Participants in an Internet-based posttraumatic stress group showed significantly greater improvement than participants in a waitlist control condition for trauma-related symptoms.27 During the first 6-month period of operation, an Australian cognitive-behavioral program for depression had more than 800 000 hits.28 In an uncontrolled study of a small subsample, use of the program was associated with a significant decrease in both anxiety and depression.
STUDIES OF INTERNET-BASED PROGRAMS
Model 1 : A Web-based Program to Prevent and Treat Eating Disorders
During the past 8 years we have developed, refined, and evaluated an Internet-delivered psychoeducationaJ program to help women improve their self-image and reduce eating disorder risk. We chose this focus because eating disorder behaviors and symptoms are common and important problems, particularly affecting young women, and efficacious, structured, face-to-face, and self-help programs that are adaptable to the Internet have been developed. Each week participants are expected to read a section of the program covering a variety of topics such as nutrition, exercise, body image, and eating disorders, complete interactive or cognitive-behavioral exercises, and participate in a moderated online discussion group with other participants.
The first step was to develop and evaluate a CDROM version of the program (called Student Bodies). Fifty-seven women from a private university were recruited and randomized to use Student Bodies with an electronic discussion group or to a waitlist control group.29 At post-treatment the intervention group demonstrated a significantly greater reduction in body dissatisfaction than the control group. Effect sizes (adjusted for changes in the control group) for the primary variables were modest, ranging from 0.3 to 0.6.
Given the encouraging outcome from this study and the evolution of online technology, the program was revised and made available online. The content of the program remained essentially the same. Sixty-one students at a public university in California were randomized to Student Bodies or to an untreated, wait-list control group.30 At follow-up, 3 months post-treatment, intervention participants reported a significant improvement in body image and a decrease in drive for thinness compared to controls. The baseline to post-intervention group was 0.4 and 0.7, respectively. While these results were promising, the mean adherence was less than 50% for the final 4 weeks of the program. We felt the program could be more effective if adherence was increased.
The next study31 was designed to enhance the outcome of the Web-based intervention by increasing adherence through incentives (class grades) and adding a course reader. We were also interested in comparing an Internet-based program with a traditional psychoeducational class. Seventy-six students from a private university were randomly assigned to one of three groups: Student Bodies, Body Traps (psychoeducational class), or wait-list control.
On average, the Student Bodies participants read 71% of the assigned online screens and posted 64% of required discussion group messages. The effect sizes of Student Bodies ranged from 0.3 to 0.8 from baseline to post-test and from 0.2 to 0.8 from baseline to follow-up, depending on the measure, compared to controls. Participants tended to log on to the program most often between the hours of 6:00 PM and 7:00 pm and a surprising number of logging on occurred between 10:00 PM and 3:00 am. The online intervention was more effective than the psychoeducational class.
The previously discussed three studies involved students with body image and weight or shape concerns without subclinical or clinical disorders. In the next study, students who did not meet criteria for a clinical eating disorder but had some clinical features of bulimia participated in a 6-week, synchronous, online discussion group facilitated by a mental health professional combined with the psychoeducational course. Sixty women with high body image concerns were randomized to the intervention or wait-list control. At post-test (8 weeks after randomization) and at 10 week postintervention follow-up, intervention subjects had significantly greater reductions in weight or shape concerns than the control group.32
These studies suggest that online psychoeducation programs combined with facilitated discussion groups are improving attitudes and behaviors related to eating disorders. In a large, multicenter study, we are now investigating whether the program can reduce the incidence of eating disorders.
Model 2: Internet Groups and Online Psychoeducation
As we explore the use of the Internet, we have been interested in developing facilitated online support groups that begin approximating the characteristics of face-to-face support groups. Toward this end, we decided to examine the effects of a Web-based support group on reducing distress and increasing coping among women recently diagnosed with primary breast cancer.
The program, called Bosom Buddies, was developed to provide a psychosocial group as an alternative to face-to-face support groups. A new topic related to breast cancer was introduced each week and a mental health professional facilitated a discussion on these topics and related concerns. Bosom Buddies encourages participants to openly and honestly express their thoughts and emotions, receive and offer support, and learn new ways to cope with having cancer. To facilitate each group member's ability to make emotional connections with other members, participants wrote a one-word or two-word description of how they were feeling when they logged onto the Web site. The group format is asynchronous; the participants could log on and post comments at any time without depending on others being online at the same time. The facilitator's primary task was to keep the conversation on the theme of the weekly topic and to encourage members to support one another. Participants logged onto the Bosom Buddies Web site an average of 34 times (SD =29, range 3 to 122) during the 12 weeks of the program.33 Compared to the wait-list control group, the intervention group reported significantly reduced depression, cancer-related trauma, and perceived stress scores. Although not significant, 52% (IO of 19) of intervention patients, compared to 30% (5 of 17) of controls, who had scored above the 16-point cut-off for depression on the Center for Epidemiological Studies for Depression Scale, no longer met this criteria at follow-up.
This study demonstrated that women with primary breast cancer and interest in an Internet group received significant benefit from participating in an online support group. However, the study needs to be replicated in a wide variety of populations including patients with lower education levels and computer literacy. A comparison with a face-to-face group and long-term followup with larger numbers of patients will also be needed to demonstrate the effectiveness of the online program.
ETHICAL. PROFESSIONAL PRACTICE. AND SAFETY ISSUES
The use of Web-based interventions presents a number of ethical and professional practice issues that are only highlighted in this article. Privacy is perhaps the most significant concern. The Internet creates an environment where patient information can be easily accessed and disseminated. Patients are also at risk for purposely and inadvertently disclosing their own and, in interventions that use social support groups, other patients' private information. Although programs can be password protected and electronic records now need to follow federal privacy guidelines, participants must be clearly informed that confidentiality of records cannot be guaranteed.
The use of the Internet raises a number of practice issues, including the possibility of providing service to patients that a professional has not seen or to patients in other states and countries. Professional organizations have developed guidelines for such activities as online consultation34 (eg, www.ismpo.org).
Because of its accessibility, patients are likely to turn to the Internet in times of crisis and to report suicidal and homicidal thoughts. Although providers that use e-care support groups have developed statements to clearly inform patients that the medium is not to be used for emergencies, patients may ignore such instructions and providers need to identify ancillary procedures.
Technical accuracy and semantic precision do not equate with effectiveness35 and diffusion will be faced, even with effective innovation.36 There is an urgent need for controlled studies in this area at almost all levels. The efficacy of structured intervention needs to be demonstrated before effectiveness trials are undertaken. Both simple and sophisticated integrated programs need to be developed and evaluated. Long-term studies with representative populations are also needed. Ethical, safety, and professional issues need to be addressed.
By facilitating the combination and delivery of interactive, evidence-based, psychoeducational programs, as well as information and psychosocial support, the Internet has the potential to revolutionize the delivery of mental health services, including increasing accessibility to mental health services for many underserved populations.
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