The growth of the Internet and its projected effectsin the next decade will have implications for thepractice of all forms of medicine, including psychi-atry [1,2]. Perhaps more importantly, the growth ofthe Internet has enormous potential for facilitatingthe development of mental health literacy in thecommunity and for providing mental health pro-grams accessible to many who do not seek or can-not access professional treatment. In the area ofhealth and mental health, websites are very popular,with sites such as the Mental Health Net [3] report-ing 400 000 hits per month [Dombeck M: personalcommunication].

The qualities that have led to the explosion of theInternet in the last 10 years have been: (i) its accessi-bility from multiple geographical sites at all times ofthe day (hence its convenience and its global reach);(ii) the opportunity it provides for rapid dissemina-tion of information; (iii) the ability of the site authorto quickly update information at little cost; (iv) itsattractive format, capacity for interactivity and poten-tial for multimedia presentation; and (v) the range ofinformation available. These qualities can lead tonegative outcomes through, for example, the fast dis-semination 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 mentalhealth disorders. We identify a number of areaswhere the WWW has potential for promoting clini-cal practice and mental health literacy. We alsoidentify areas of potential disadvantage and dangerof the new technology.

The Internet and mental health literacy

Helen Christensen, Kathleen Griffiths

Objective: This paper describes the informational and treatment opportunitiesoffered by the Worldwide Web (WWW) and comments on the advantages, dis-advantages and potential dangers of its role in mental health and mental healthresearch.Method: Two perspectives are taken: (i) the impact of the Web from the point ofview of the clinician (the practitioner view) and (ii) the impact of the Web on thepublic’s knowledge of mental health (mental health literacy; the community or publichealth view). These perspectives are applied to two areas of impact: (i) informationand knowledge; and (ii) treatment and self-help.Results: The Web, due to its accessibility, has advantages in providing access toinformation, online therapy and adjunctive therapy in mental health. Problemsinclude information overload, poor information quality, potential harm and lack ofscientific evaluation.Conclusions: Issues of overload and quality of information, the potential for harmand the need to evaluate interventions are not unique to the Internet. However, theInternet has special features which make these issues more prominent. The Internetis likely to increase the general public’s access to information and to decrease unmetneed. Sites and interventions on the Internet need to be formally evaluated.Key words: Internet, mental health, prevention, treatment, websites.

Australian and New Zealand Journal of Psychiatry 2000; 34:975–979

Helen Christensen, Senior Fellow (Correspondence); KathleenGriffiths, Visiting Fellow

Centre for Mental Health Research, Australian National Uni-versity, Canberra, Australian Capital Territory 0200, Australia.Email: helen.christensen@anu.edu.au

Received 31 March 2000; revised 7 June 2000; accepted 14 June2000.

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 Webon the public’s knowledge of mental health (mentalhealth literacy; the community view or public healthview). These two perspectives are not independent,but provide a useful platform to examine the issues.These perspectives are applied to two areas ofimpact: (i) knowledge and information and (ii) treat-ment and self-help.

Knowledge and information

The practitioner view

The WWW provides information that might servea number of purposes for the psychiatrist or mentalhealth professional in clinical practice. First, infor-mation of use to the practitioner’s clinical work andcontinuing education is available. This includesimmediate access to information about drugs, side-effects and therapies; to journal articles, books, recentnewspaper reports; and professional sites. Informationis available about clinical practice guidelines and theeffectiveness of interventions from sources such asthe Cochrane collaboration. The Internet may also beused for meetings or virtual conferences.

Second, information that might be used to facilitatepatient management and education is also availableon the Internet. Clinicians may develop a portfolio ofuseful sites that provide information they consider ofvalue for their patients. They may, for example, referpatients or their families to sites about depression.Clinicians with their own sites might post specificinformation for their patients (and the patient’s rela-tives) about doses, side-effects, further referral, afterhours assistance and other topics relevant to the pa-tient’s management and recovery.

The community view

From the community health perspective, a widerange and quality of mental health information isavailable for use by consumers on the WWW [4,5]including extensive sites such as Internet MentalHealth [6] and Mental Health Infosource [7]. First,potentially, such information may inform the publicabout the nature and effective treatment of mentalhealth disorders. An increasing number of Australiansregularly access the Internet. For example, approxi-mately 75% of all 18–24-year-olds in Australia

accessed the Internet in the 12-month period prior toMay 1999, compared with 49% in the previous year[8]. The resulting increased access to mental healthinformation will produce more informed patients,resulting in a change in the knowledge relationshipbetween patient and doctor. Perhaps more impor-tantly, people with symptoms or needs who do notseek professional help may nevertheless access infor-mation about mental health on the WWW. This isimportant since it has been estimated that only aminority of people with mental disorders in the com-munity seek professional help [9].

Second, the WWW is also a potentially usefulmedium for educating practitioners and public healthorganisations about consumers’ views of the approp-riate treatment for psychiatric illness and consumerperceptions of the limitations of current treatments.Although information on websites is not necessarilyrepresentative of community views, mental healthproblems are often unrecognised and consumers’beliefs about treatment suitability may be importantin selecting the most effective treatment or preven-tion for them [10].

In short, information on the WWW has the potentialto inform psychiatrists, educate patients (or carers)about treatment, assist the community in identifyingcommon mental disorders and potentially useful treat-ments and inform the medical profession and the pub-lic health community about the views of consumers.

However, there are potential problems arising fromthe availability of this information. Yellowlees andBrooks [2] have identified these as information over-load and information quality. Information overload isa major problem. Internet programming experts haveestimated that it would take approximately 50 000person-years to read all the pages of the Internet[Hawking D: personal communication]. Meanwhile,the number of sites continues to proliferate and thesemay be huge or poorly organised making it difficultto find relevant information.

Search engines have been developed to retrieveinformation from the Web and reduce the number ofpages presented as potentially useful to the user (see Hawking et al. for a review of search engineeffectiveness [11]). However, even the best of thesesearch engines lack retrieval precision. One responseto this problem is to develop portal websites dedi-cated to health, mental health or a particular mentalhealth issue. These sites usually consist of a collec-tion of specific content, indexed, and a local searchengine together with links to other recommendedsites. The usefulness of such portals still depends on

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the sites referenced and the quality of the attachedsearch engine. Future portals will no doubt providesubject-focused searches over a wide range of ex-ternal sites, but a number of technical and legal prob-lems need to be solved to achieve comprehensivehigh-quality coverage.

The second issue concerns the quality of inform-ation on the Internet. One major concern is that con-sumers (and practitioners) will obtain inaccurate orpotentially dangerous information [12,13]. The egali-tarian nature of the Internet allows any individual topost a site. There are many examples of poor sitespromising untested treatments for depression [5]. Anumber of evaluation criteria have been proposed[14]. The most frequently used are the accountabilitycriteria of Silberg, Lundberg and Musacchio [15]which require the user to check the site’s character-istics including when it was last updated, authorshipdetails, attribution of sources and disclosure of owner-ship. However, there is no published evidence thatthese criteria are indicators of the quality of the con-tent of sites. Validation requires the comparison ofSilberg et al. scores with a ‘gold standard’. The latterwould be based on consistency with the scientificevidence or the standard clinical practice guidelines.Internet sites devoted to physical health have beenfound to be of poor quality and to contain importantomissions [11,16]. Nevertheless, the problem ofquality may be solvable. It may be possible in thefuture to develop intelligent search engines thatoperate using algorithms validated by reference tothe ‘gold standard’.

We have recently audited 21 popular websites ondepression [12] and found that the quality of suchsites is poor, that they lack balance, and that they donot provide treatment information consistent with the‘gold standard’. They also include misinformation orinformation that could be easily misinterpreted. Forexample, one site, written by a psychiatrist, providedinformation on the means by which consumers couldidentify whether their doctor was an ‘expert’ in thetreatment of depression. One criterion for the identi-fication of this expertise was the use of the combin-ation of monoamine oxidase inhibitors with tricyclicantidepressants! However, despite the potential fordisseminating misinformation, many sites resemblethe curate’s egg in that they are good in parts.Consumer sites, for example, offer the potential toeducate mental health professionals about the issuesthat are of major concern to consumers. In ourreview, we were struck by the frequency with whichunwanted and painful side-effects of medication

were discussed and with which advice was offeredabout selecting a good therapist. This suggests furtherresearch into side-effects is warranted and that coun-selling about side-effects is essential for compliance.

Treatment or treatment supplementationand self-help

The practitioner view

From the perspective of the clinical practitioner,the Web may provide a forum for mental health diag-nosis, therapy, management and support. Exampleswithin medical practice include the use of Internet-assisted diagnostic instruments and the use of case-conferencing facilities to link patients with otherspecialists or mental health professionals. As an ad-junct to treatment, psychiatrists might also recom-mend chat groups as a means of social support forisolated patients, albeit that there may be somedangers in these groups if the patient is left unsup-ported (see below).

The community view

More controversial is the use of the WWW as ameans of self-help, and this use has public healthimplications. For example, for depression, individualonline therapy is available for those with access tosites and financial resources. A popular site is Cyber-psychologist [17], which provides an online self-helpservice. The website www.metanoia.org [18] listsover 160 therapists who provide online counsellingincluding many who provide ongoing contact bymeans of email or chat sessions. Computer-assistedtherapy programs for depression can be purchased,downloaded and used at home [19]. Information isavailable about purchasing and making correct doseantidepressants using St John’s Wort and a variety of other herbs and potions including kava, coffee,gingko, vitamins, tryptophan and many others. A rangeof self-help lifestyle changes are documented to helpdepression 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 bereadily accessed. If chat groups, monitored by a pro-fessional chat group host can be regarded as grouptherapy, this already exists at multiple sites. Specificinquiries about problems of young people can beanswered at Go Ask Alice [20]. The actual behaviourof ‘surfing the Net’ may also be seen to be a form of

H. CHRISTENSEN, K. GRIFFITHS 977

occupational therapy, and of potential benefit. Thesociocultural implications of bringing people togetherhave yet to be explored, but this new ‘connectedness’may contribute to social capital and promote mentalwellbeing.

There are public health implications of the avail-ability of these services on the Internet. The firstproblem is the potential harm that might arise fromthese activities. There is little concern about the useof Web services as an adjunct to treatment or sourceof discussion in a clinical setting. However, onlinetherapy, alternative treatments, self-diagnosis andchat groups have been claimed to be harmful or evendangerous [21]. Online therapy may be of poorquality, inappropriate, conducted by untrained practi-tioners, use insecure message systems which violatepatient privacy and produce dramatic negative effects.Self-diagnosis feedback could lead to great anxiety.Chat groups, where comments reign unchecked byeither host or other participants may be extremely dis-tressing. Cyberstalking has recently been reported [22].

The second related problem is the lack of evidenceabout the effectiveness or otherwise of these services.To our knowledge, none of these site activities havebeen appropriately evaluated. There is some evidencefrom uncontrolled trials that suggests Internet use ingeneral may decrease social interaction and increaseloneliness [23,24]. The validity of self-assessmentinstruments administered via the Internet has beenreported [25]. However, the effectiveness of onlinetherapy activities has not been evaluated systemati-cally. Over 90% of a sample of more than 400 onlinecounselling clients reported in a survey that Internettherapy assisted them [26]. However, the surveywould appear to have been conducted on a self-selected sample, with no control group and limitedoutcome measures.

Nevertheless, it is highly probable that interven-tions using the Internet will be found to be effective.There is evidence that self-help using non-Internetresources can work. Bibliotherapy is reported to behighly effective in the treatment of depression [27].Computerised therapy has also been found to be aneffective medium [28] and may translate easily to theInternet. It is possible that interactive, multimediasites using proven therapies and developed using aneducational format may be as effective or more effec-tive than other self-help mediums. These programshave the potential to be accessed by those who wouldnot normally seek professional help or those in ruralareas, for example, where access to psychiatrists orpsychologists is not possible. Moreover, it will be

possible to track user behaviour on the sites, to deter-mine the most ‘attractive’ features of the packages.While use of the Internet is associated currently withhigher education, it has the potential to decreasesocial inequalities as it becomes ubiquitous.

Conclusions and future directions

Issues of overload and quality of information, thepotential for harm and the need to evaluate interven-tions are not unique to the Internet. For, example, ithas been reported that four million articles are addedto the biomedical literature each year [29]. However,the features of the Internet which exacerbate theseproblems are its immediate accessibility and capac-ity for fast dissemination.

The Internet is likely to facilitate access to infor-mation, to increase mental health literacy and to pro-vide a broader range of information for those outsidethe medical sphere. Those who do not traditionallyseek medical help may be helped and those withearly symptoms may reach help earlier. Knowledgeand treatment via the Internet may decrease unmetneed. More specifically, the likely effects of the Inter-net on the psychiatrist’s role would be that suchtherapy and information, if available and of goodquality, could be harnessed for use as an adjunct totherapy. The increase in mental health literacymight lead to additional consultations for psychi-atrists and other professionals. Our recent audit ofdepression sites found that all 21 sites recommendedthat depressed people seek the help of a health pro-fessional [5].

What is most clear is the research agenda. Aprogram to evaluate Internet-based mental healthinformation with respect to what is known scientif-ically is highly desirable. There is a need to estab-lish whether search engines can be developed whichassess the quality of website information. The pos-sibility of attempting to establish packages of‘therapy’ on the Internet is exciting, although thepotential dangers of such interventions need to beaddressed simultaneously. Finally, there is a clearneed to evaluate Internet interventions systemati-cally, albeit that what is being evaluated is likely tobe a movable feast.

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