E-psychiatry

Dr Eduardo de la Sota Guimón examines the potential of the internet in mental health

The uses of the internet in psychiatry have increased in recent years, and there is evidence that professionals, patients, families, institutions and other agents benefit from it.

Photo: E-psychiatry

More information and more communication between those who share the mental health network generates quality, efficacy and efficiency in mental health services delivery. Nevertheless, different researchers have obtained their own conclusions. Thomas Kramer and Robert Kennedy (USA) pointed out the following internet uses: Traditional literature: Traditional journals are increasing going online. The British Medical Journal was among the first, soon followed by the American Journal of Psychiatry and many others. Traditional literature can be searched via various MEDLINE sites, but perhaps the most complete is PubMed, at the USA’s National Library of Medicine.
Reference Material: This includes treatment guidelines, for example. The American Psychiatric Association and the ‘Expert Consensus’ series are online. There is also information specifically for patients - or for psychiatrists to give to patients. Drug information from the US Pharmacopeia can be obtained from InteliHealth at Johns Hopkins. My ‘Student Counselling Virtual Pamphlet Collection’ is a directory of educational material produced by university student-counselling centres located literally around the world. With the advent of improved data compression and transmission technologies, multimedia is becoming more prevalent. Visiting-lecture series at the University of Chicago, for example, can be listened to and watched live over the Internet. Internet resources: Here, we refer to resources that exist only on the Internet and are not just online versions of information in print. Psychopharmacology Tips, provides practical psychopharmacological information, culled from Ivan Goldberg’s psychopharm mailing list, on over 400 topics. There are also publications that are only available online. A good example, in the news lately because George Lundberg moved there from JAMA, is Medscape. Another category of Internet resource is compiled by patients rather than physicians. One of the first was Pendulum, started by a group of bipolar patients.
Virtual Communities: There are resources that emphasise interaction more than information. Interpsych is a group of mailing lists (or ‘listserves’) that focus on different aspects of psychiatry, e.g. psychopharmacology or child psychiatry. Behaviour OnLine offers a variety of specialised bulletin boards featuring experts in those areas. Psycho-Babble is a bulletin board of mine for mutual education and support, frequented mostly by patients. At Concerned Counselling, there are different ‘real-time’ chat rooms, again used primarily by the public.
On-line Psychotherapy: Right now, the cutting edge of psychiatric use of the Internet  is online therapy. It’s controversial, but is happening. Metanoia has a directory of providers (and related information) in the US. http://www.metanoia.org/imhs/ongoing.htm
According to James R Alleman (2003), although the prospect of online mental healthcare raises obvious questions, it also offers an opportunity to make cost effective services available to many who might not otherwise have access. By understanding issues such as confidentiality, emergencies and lack of face-to-face contact, psychiatrists can determine if this area of treatment is right for them. People who are troubled are beginning to turn to the Internet to seek psychotherapy. Avoiding the embarrassment and inconvenience of a face-to-face appointment, patients can easily find a therapist and receive professional counselling via a computer in their own home. One researcher’s database of online ‘e-therapy’ resources has already grown to 300 private practice Websites, as well as a number of online clinics through which another 500 professional therapists can be contacted (Ainsworth, 2002). When surveyed, online patients seemed happy with their treatment (Ainsworth, 2002) and, judging by the rapidly growing professional membership of the International Society for Mental Health Online (ISMHO), there are also respected therapists convinced they can do good work over the Internet (ISMHO, 2002). Since the World Wide Web cannot be unspun, there is every reason to believe that people, especially the young and computer-literate, will continue using it to seek mental health services.
Lange et al (2006), published an article concerning evidence about the effects of internet-based psychotherapy in improving symptoms of post-traumatic stress disorder. They found one RCT (25 people) that compared internet-based psychotherapy versus waiting list control for five weeks. It found that, at five weeks, internet-based psychotherapy significantly improved intrusive symptom score from baseline compared with waiting list control (mean reduction: 11.0 with internet-based psychotherapy v3.6 with waiting list control; P < 0.04) and reduced avoidance score (mean reduction: 9.6 with internet based psychotherapy v2.9 with waiting list control; P < 0.03). The RCT gave no information on adverse effects. The authors concluded that there is some evidence from one small RCT that internet-based psychotherapy might be effective.
Although many people use the Internet for health information, this is not as common as sometimes reported, according to Baker et al (2003). Effects on actual healthcare utilisation are also less substantial than some have claimed. Discussions of the role of the Internet in healthcare and the development of policies that might influence this role should not presume that use of the Internet for health information is universal or that the Internet strongly influences healthcare utilisation.
Recently, Hsu et al (2005) concluded from their study in San Francisco that access to and use of e-health services are growing rapidly. Use of these services appears to be greatest among people with more medical need. The majority of subjects, however, do not use any e-health services. More research is needed to determine potential reasons for disparities in e-health use by race/ethnicity and SES as well as the implications of these disparities on clinical outcomes.
Powell & Clarke (2006) pointed out that 18% of all internet users had used the internet for information related to mental health. The prevalence was higher among those with a past history of mental health problems and those with current psychological distress. Only 12% of respondents selected the internet as one of the three most accurate sources of information, compared with 24% who responded that it was one of the three sources they would use.

30.10.2007

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