ABSTRACT

Advent of the Internet as a medium of mass communication poses numerous opportunities, challenges and dilemmas for mental health professionals; especially those in the developing countries. The Net is a cost-effective alternative and supplement for the conventional methods of education and research. Online-publishing offers a solution to the low visibility of research from developing countries. Mental health professionals have to be aware of the advantages and disadvantages of methods of online patient care, like physician-patient e-mail, telepsychiatry, educative websites, and online psychotherapy. Internet revolution has introduced Internet addiction disorder, Munchausen syndrome through Internet, Internet pedophilia and Internet delusions; and the Net is being misused to promote drugs. Developing countries should address the issues of poor penetration rate and dearth of websites in non-English languages.

INTRODUCTION

The Internet has been described as the most important development in global communication since both the television and the telephone (Al-Shahi et al., 2002). An estimated 12.7 % of the world’s population currently uses Internet, with a user growth of 125.2 % in the last four years (Internet World Stats, 2004a). Health is probably the largest single category of information hosted by the Internet, and over two thirds of the online public seeks information about it (Harris Interactive, 2002). Articles that discuss how the Net is changing the day-to-day practice of Psychiatry have already appeared in major psychiatric journals (For e.g., Huang and Alessi, 1996; Al-Shahi et al., 2002, Styra, 2004). This article outlines the implications of the increasing popularity of the Net for mental health professionals, especially those in the developing countries. The opportunities for education, research and patient-care offered by the Net; the impact the Net has on the mental health of its users; and some limitations in the current scenario are discussed.

ONLINE EDUCATION

Healthcare workers in the developing world have for years had the problem of very limited access to the latest information that is the lifeblood of effective health care (Godlee et al., 2000). Whereas the professionals in the developed world have information overload, the developing countries have bare library shelves; and the Internet provides an opportunity to narrow this gap (Kennard, 2001). Various open-access and free access journals, online guidelines and articles, and official and personal websites provide the medical professionals across the globe with an unprecedented access to invaluable information. Under the auspices of the World Health Organization, leading medical publishers have agreed to provide free access to electronic versions of journals to people working in developing countries (Kmietowicz, 2001).

Online Publishing and Developing Countries

Concerns have been raised about the low visibility of research from developing countries. While Zielinski (1995) found that 98% of journals indexed by Western services such as Medline are from the developed world, Patel and Sumathipala (2001) reported that 94% of the articles published in six leading psychiatric journals over a three year period were from Euro-American countries. The psychiatric problems of the world’s poor, and research aimed at the resolution of those problems, do not feature significantly in the psychiatric journals with the highest impact factors.

The advent of Internet has made it possible for authors, institutions and professional organizations in developing countries to bypass traditional avenues of scientific publishing, and to post their research directly on their own websites. Online journals are easier to publish; the tempo of publishing is accelerated; the articles may contain colored graphs, photographs, X-ray pictures, PET scans, or even video sequences, without any additional costs; hyperlinks to the cited references make it easy to access the original literature; and the authors could be directly contacted by means of the E-mail address provided in the article (Bandelow, 2000; Obst, 2003; Styra, 2004). On-line versions of articles are found to be accessed more often than their print versions (Obst, 2003), and some psychiatric journals like German Journal of Psychiatry <http://www.gjpsy.uni-goettingen.de/> appear only online, without any printed version.

The Indian Medlars Centre of National Informatics Centre, New Delhi, has designed two databases, IndMED, a bibliographic database of peer reviewed Indian biomedical journals and medIND, full-text of select IndMED journals. These are accessible free of cost from the Center’s site <http://indmed.nic.in/>. An increase in visibility and International submissions has been noticed for online Indian journals like Journal of Postgraduate Medicine <www.jpgmonline.com> (Scaria, 2004). Unfortunately, most of the Indian journals on mental health are still not online. There is an urgent need of the journals published by professional organizations and institutions to go online and increase their visibility. Assistance of agencies like Bioline, a not-for-profit electronic publishing service for providing open access to journals from developing countries <http://www.bioline.org.br/>; JournalServer.org <http://www.journalserver.org/>, an online library of academic journals; or aippg, <http://www.aippg.com/free-hosting/>, a site that offers free hosting for medical websites, may be sought to achieve this goal.

Open Access

Open Access by definition means “immediate, permanent, toll-free, non-gerrymandered, online access to full text” (The Budapest Open Access Initiative Definition). Open Access may be considered as borne on three pillars- Open Access Archiving, Open Access Publishing, and Open Access Support/Advocacy.

Open Access archiving: Open Access archiving, or the deposition of scholarly research papers into networked servers accessible over the Internet, is one development that has great potential value for poorly resourced countries. Since 1991, high energy physics researchers around the world have networked through an eprint archive - 'Arxiv' - <http://arxive.org/>. Arxiv receives two-third of its two million weekly hits from institutions outside the United States, including many research facilities in developing regions. The success of Arxiv led to the creation of the Open Archives Initiative which has developed E-Print <www.eprints.org> software which would enable interoperability between different archives encompassing different specialties. These data are available through search engines like OAIster <http://oaister.umdl.umich.edu/o/oaister>. The new wave has swept through the biomedical domain too, with a number of institutional and centralized archives like Cogprints <http://cogprints.soton.ac.uk/> being established (Scaria, 2004).

Open Access Journals: Journals are increasingly finding it a viable option to go Open Access given the fact that many Open Access Journals have rapidly built upon readership base, visibility and impact. A recent analysis revealed that the impact factors of nearly 200 open-access journals are similar to those of traditional journals in the same fields, and that they are doing better in some categories. For e.g., the Journal of Psychiatry and Neuroscience <http://www.cma.ca/jpn/index.htm> was ranked in the 70th percentile in the medicine category (McCook, 2004).

News on the Open Access movement could be viewed at the blog “Open Access News” <http://www.earlham.edu/~peters/fos/fosblog.html>.

Difficulties, Limitations and Precautions

Psychiatrists’ use of online resources are affected by factors like awareness of the existence of on-line programs, interest and motivation to use new technology, quality and currency of the content, an educational format that is not only easy to use but also intellectually engaging, cost, registration requirements, etc. (Styra, 2004). Casebeer et al., (2002) found that the most common reason physicians sought information on the Internet was to solve a specific patient problem, and the major barriers they faced in the process were “too much information to scan” and “too little specific information to respond to a defined question”. Lack of regulation and commercial exploitation has led to an excess of poor quality health information in the Net, and studies have revealed poor quality of websites on depression (Griffiths and Christensen, 2002) and eating disorders (Murphy et al., 2004).

The poorest countries are unable to sustain the essential ICT infrastructure even at their major hospitals; and there is a continuing remoteness of health professionals working in remote district hospitals and clinics from electronic information sources which would be appropriate to their limited resources (Patrikios, 2000).

Psychiatrists should be aware that an extensive array of guidelines are available online and that patients or their families may challenge them to explain discrepancies between their treatment and evidence-based guidelines found on the Internet (Styra, 2004). Bandelow (2000) reminds authors publishing medical articles on the Internet that their articles could be read also by patients and their relatives, but also adds that this is not necessarily a disadvantage in all cases.

DOING RESEARCH ONLINE

The possibility of conducting clinical trials entirely online is an enticing medical application of the Internet. The penetrance of the Internet in the population offers the possibility of rapid recruitment of participants, and technological advances enable instant collection of data in a secure and confidential manner (Carey, 1997). Computer-assisted assessment is cheaper and more efficient than clinical interviews or paper-and-pencil questionnaire (Budman, 2000). Nicholson et al. (1998) criticize that Internet research is likely to impose a bias toward male, better educated, and more computer-involved samples on the respondents reached. Brosius (2001) lists the following advantages and disadvantages of Internet research:

Advantages:

• Inexpensive (low distribution cost)

• Fast (return of results within days)

• No personnel needed

• Multimedia presentation possible

• Large samples possible

• Automated data entry

Disadvantages:

• Sampling problems (What is the population?)

• Low response rate; self-selection by respondents

• Technical problems (eg, browser differences, resolution, etc)

• Brevity of questionnaire

• Unclear response

• Multiple participation

INTERNET AND PSYCHOPATHOLOGY

Depression

Morgan and Cotten (2003), in an Internet survey of college freshmen at a mid-Atlantic mid-sized university, detected that an increased e-mail and chat room/instant messaging (IM) hours are associated with decreased depressive symptoms, while increased Internet hours for shopping, playing games, or research is associated with increased depressive symptoms. However, young Internet users with depressive symptomatology are more likely to be the targets of Internet harassment and unwanted Internet sexual solicitation (Ybarra, 2004; Ybarra et al., 2004).

Munchausen Syndrome through Internet

Feldman (2000) coined the term "Munchausen by Internet” to refer to people whose factitious disorder manifest online. These patients click from one patient support group to another, can join multiple groups simultaneously under the guise of illness, can use different names and accounts, and can even sign on to one group with multiple identities. Feldman (2000) suggests the following clues to the detection of factitious Internet claims.

1. The posts consistently duplicate material in other posts, in books, or on health-related websites
2. The characteristics of the supposed illness emerge as caricatures
3. Near-fatal bouts of illness alternate with miraculous recoveries
4. Claims are fantastic, contradicted by subsequent posts, or flatly disproved
5. There are continual dramatic events in the person's life, especially when other group members have become the focus of attention
6. There is feigned blitheness about crises (e.g., going into septic shock) that will predictably attract immediate attention
7. Others apparently posting on behalf of the individual (e.g., family members, friends) have identical patterns of writing.

When Munchausen by Internet seems likely, it is best to have a small number of established members gently, empathically, and privately question the author of the dubious posts. Even though the typical response is vehement denial regardless of the strength of the evidence, the author typically will eventually disappear from the group. Remaining members may need to enlist help in processing their feelings, ending any bickering or blaming, and refocusing the group on its original laudable goal.

Internet Addiction Disorder

The concept of Internet addiction entered the medical dictionary in 1995. According to the model proposed by Grohol (1999), most people with Internet addiction are likely newcomers to the Internet, going through a stage of acclimating themselves to a new environment – as this environment is larger than anything they have seen before, some people get "stuck" in the acclimation stage for a longer period than is typical for acclimating to new technologies, products, or services. Types of Internet addiction include "cybersex", chat rooms, and net gaming"; the pathological search for information or video games being the most frequent (Dejoie, 2001). Shapira et al. (2000) studied persons with problematic internet use (n = 20). All the subjects were found to meet DSM-IV criteria for an impulse control disorder not otherwise specified, and to have at least one additional lifetime DSM-IV Axis I diagnosis, with 70.0% having a lifetime diagnosis of bipolar disorder.

Internet Delusions

Delusions, especially in patients with schizophrenia, often reflect the sociocultural characteristics of the epoch, and delusions regarding the Internet have started appearing (Tan et al., 1997; Catalano et al., 1999; Kobayashi, 2001). The Internet has many characteristics that are compatible with such abnormal schizophrenic experiences as thought-broadcasting and worldwide delusional systems, and thus seems to be incorporated easily into the delusional systems of schizophrenia patients (Kobayashi, 2001).

Net and Substance Use

Hesselink (1998) reviews the problems posed by 'smart drugs', a new class of drugs for healthy individuals heavily promoted via the Internet. Drugs advertised via the Net include selegiline and androstenedione as aphrodisiacs, phenytoin to improve memory and intelligence, gamma-hydroxybutyrate to increase sexual desire, etc. Though their efficacy in healthy individuals is not proven and the proof offered on the Net is of a simple structure and not peer reviewed, the drugs are promoted as 'natural', having a low toxicity and a broad therapeutic window. The problems of side effects, abuse and dependency are rarely discussed. All of these drugs are freely and easily accessible via global mail order companies that ship these drugs to customers all over the world after having obtained an order via the Net. Psychiatrists and family practitioners should be aware of this source of drugs, since many of these drugs have a narrow therapeutic margin and can interact negatively with other psychotherapeutic agents. Psychiatrists need to understand that especially younger patients might make use of these drugs, in varying doses and often in combinations with psychiatric medications.

Internet Pedophilia

Deirmenjian (2002) reports cases of pedophiles who used the Net to exploit child victims, and explores the role that mental health professionals may play in the assessment of Internet pedophilia. Mental health professionals may provide psychiatric treatment to victims of Internet pedophiles, may be involved in the evaluation of perpetrators of Internet crimes in a clinical or forensic setting, or Governmental agencies, the criminal justice system, school, or the media may request consultations by mental health professionals as part of a multi-disciplinary approach to prevention. The author discusses two models of pedophilia on the Internet: a trust-based seductive model and a direct sexual model.

ROLE OF INTERNET IN THE MANAGEMENT OF PSYCHIATRIC DISORDERS

Internet and modern technologies provide a reliable, alternative solution in the provision of medical advice, adjuvant to the conventional medical services. Websites can provide information to patients and their relatives; and health-related online communities can provide social support (Pleace et al., 2000), reduce isolation (White et al., 1999), and can help people cope more effectively with their disease (Klemm et al., 2003). Due to stigma or the interpersonal communication problems associated with the psychiatric disorders, many patients and their relatives may use the Internet as a first step for obtaining information or even to initiate contact with a physician. A set of principles of professional ethics for the online provision of clinical mental health services have been produced by a joint committee of the International Society for Mental Health Online and the Psychiatric Society for Informatics (Hsiung, 2001).

Educative Websites

As of November 2004, the Open Directory Project <www.dmoz.org> lists 6,506 websites in its “Mental health” category, of which 3,866 sites are in the “Disorders” subcategory. Although mental health websites are regarded as a useful adjunct to therapy, concerns had been raised about the use of such sites as a "Band-Aid," which may delay or prevent consumers from obtaining much-needed mental health care (Christensen and Griffiths, 2002; Budman, 2000).

Labiris et al. (2003) report that 40.9% of the psychiatric patients who visited their medical site seeking medical advice expressed their satisfaction, while 48.5% of stated that the service was essential in understanding their problem. Azocar et al. (2003) found that providing members of a managed behavioral health organization with free Web site access did not appear to promote or delay their use of mental health services. Christensen et al. (2002) evaluated the efficacy of a psychoeducation website offering information about depression and an interactive website offering cognitive behaviour therapy for community-dwelling individuals with depressive symptoms. Both the interventions were found to be more effective than a credible control intervention in reducing depressive symptoms. The Web-Based Depression and Anxiety Test, a web-based self-report screener, have been found reliable for identifying patients with depression and various anxiety disorders (Farvolden et al., 2003). Copeland and Martin (2004) reviewed a number of computerized and Internet-based interventions for substance use disorders, and found most of them to be largely descriptive, with no large randomized controlled trials of Internet-delivered interventions for substance use disorders reported.

Internet Communities

The Internet communities consist of individuals seeking assistance with problems such as depression, suicidal tendencies, substance abuse, cancer, and eating disorders (Finfgeld, 2000). These communities provide users with information and a platform for peer-to-peer communication that may be synchronous (e.g. chatrooms) or asynchronous (e.g. messageboards). Caregivers of Alzheimer disorder patients (White and Dorman, 2000), teenage smokers (Woodruff et al., 2001) and problem drinkers (Pleace et al., 2000) have been shown to use online support groups. Many users find it easier to discuss mental health topics online rather than in person, and have reported benefits in terms of information, social support and contact (Agrell and Walinder, 2002; Houston et al., 2002; Kummervold et al., 2002]. Most of the users perceive discussion groups as a supplement rather than a replacement of traditional mental health services, and want professionals to take an active role in these types of forums (Kummervold et al., 2002).

The possible limitations of Internet communities include abuse by users offering false stories (Feldman, 2000); concerns over the dissemination of inaccurate information (Desai et al., 1997); exclusion of certain groups through the 'digital divide'; and the misinterpretation of online messages lacking in visual or aural cues (White and Dorman, 2001). Humphreys et al. (2000) provide an appraisal of psychologists' ethical responsibilities in online discussion, support, and self-help groups and offers practical strategies for avoiding ethical problems.

Telepsychiatry

American Psychiatric Association defines telepsychiatry as “the use of electronic communication and information technologies to provide or support clinical psychiatric care at a distance” (American Psychiatric Association, 1998). APA discusses a number of applications of telepsychiatry, including clinical interviews, emergency evaluations, case management, and supervision of procedures such as electroconvulsive treatment, and clinical supervision of remote trainees. The disadvantages of telepsychiatry include compromised relationship between health professionals and the patients, the need for major organizational changes, equipment costs, and the need for training of staff and maintenance of the equipment (McLaren, 2003). With a shortage of trained mental health professionals to attend to a rural population nearing 700 million, India is expected to benefit enormously from use of telepsychiatry. The e-mail helpline of Central Institute of Psychiatry, Ranchi <cipranchi@hotmail.com> is being extensively used by patients and their relatives across India.

Physician – Patient E-Mail

E-mail has the potential to enhance the professional relationship between physician and patient. Baker et al. (2003) found that 6% of US households over age 21 use e-mail to contact a physician or other health care professional. The advantages of E-mail are that it is faster than all other forms of mail services; it can be exchanged across time zones; it is not dependent on the presence or absence of both the sender and the receiver at the two ends at the same time; and that it is less expensive than other means of communication like fax or telephone (Kapur, 2001). However, most e-mail programs/services are not secure, thus subjecting the patients to possible breach of confidentiality (Luo, 2002).

Guidelines developed by American Medical Association emphasize that e-mail should not be used to establish a patient-physician relationship, but rather to supplement personal encounters. When using e-mail, physicians hold the same ethical responsibilities to their patients as they do during other encounters and that information must be presented in a manner that meets professional standards. The guidelines require that physicians notify patients of e-mail's inherent limitations and that patients be given the opportunity to accept these limitations prior to the communication of privileged information (Bovi et al., 2003). The Canadian Medical Protective Association recommends that physicians discuss the ramifications of communicating electronically with patients and obtain documented informed consent before using e-mail (Styra, 2004).

Online Psychotherapy

E-therapy is a term that has been coined to describe the process of interacting with a therapist online in ongoing conversations over time when the client and counselor are in separate or remote locations and utilize electronic means to communicate with each other (Manhal-Baugus, 2001). Convenience is a major advantage of e-therapy, and for patients with limited mobility or suffering from anxiety disorders such as social phobia e-therapy abolishes the barrier to treatment (Luo, 2002). The American Counseling Association (1999), the American Mental Health Counselors Association (2000), and the International Society for Mental Health Online (2000) have all issued specific guidelines for online counseling. These guidelines require practitioners to give patients an alternative way to initiate contact in the event of technology failure and require the therapist to ascertain patient identity and to establish alternative ways to reach the patient or send help. An Internet-based cognitive behavior therapy intervention was found to reduce anxiety and depressive symptoms by (Christensen et al., 2002). When surveyed, online patients seemed happy with the treatment they receive (Ainsworth, 2002)

Concerns have been raised about the nonavailability of social and nonverbal cues that may facilitate the communication's context (Luo, 2002). Alleman (2003) suggests that capitalization, type size, word repetition, spacing, fonts and emoticons can become supplemental tools to compensate for the loss of visual and auditory cues. Stofle (2001) advises against exclusive online treatment for those who exhibit psychotic, borderline or suicidal symptoms.

Preventive Interventions

Christensen and Griffiths (2002) lists various features of the Internet that make it suitable for public health interventions, including its potential to reach a mass audience; cost-effectiveness of the Internet-based interventions; anonymity; and the net’s  capability of supporting individually tailored prevention programs and automated applications that guarantee intervention fidelity. The authors also note the following limitations to public health interventions using the Internet:  

• Lack of access to the Internet: Higher-income families, families with children and people living in cities rather than rural areas are more likely to have computer and Internet access (Rosen, 2000). Internet use is much less frequent among people older than 55 years. Although access may generally be lower in these groups, Internet consultation may bring significant benefits to "groups that are arguably disadvantaged in traditional medical health care" (Brebner et al., 2001).

• Individuals might not use prevention programs on the Internet: Potential users may be unaware of a website intervention, lack the motivation to access the site, or readily exit to one of the many competing sites on the Web.

THE “DIGITAL DIVIDE” AND OTHER BARRIERS

In 2004, while the 68.3 % of North America’s population uses Internet, the corresponding rate for Africa is 1.4 % (Internet World Stats, 2004a). Even in the developed countries, old and poor people have poor internet access (Wong, 2004). Notwithstanding the remarkable progress in the application of information and communication technologies in India, many of our villages still lack a working telephone (United Nations Development Programme, 2000). As on December 2003, only 1.7% of India’s population has been using the Net (Internet World Stats, 2004b). The Government of India has announced an Rs 12,410-crore technology project to bridge the divide and to develop a voice-activated, low-cost computer for the country's illiterate rural populace (Newindpress, 2003). Akshaya <http://www.akshaya.net/>, an e-literacy programme started by Government of Kerala with the aim of making Kerala the first completely e-literate state in India by 2005, is another laudable initiative.

The presence of Indian languages on the Web is very limited and still in its nascent stages. Uses of Indian languages have to overcome the technological barriers, since technology is primarily available in English and focused on the use of English. Displaying Indian scripts on available browsers and management of multilingual content is a difficult task. Moreover, browsing a new Indian Language site requires downloading of fonts and configuration of the browser. Khatri (2002) have mentioned the technical aspects on creating web pages in Indian regional languages. Anna University has recently developed 'Kazhugu', a search engine capable of searching all the Tamil websites, and this is thought to be the first search engine in an Indian regional language. Very few sites are offering e-mail in Hindi or local languages. E-mail in Hindi is available in sites like <www.ebharati.biz>, <www.langoo.com> and <www.inoman.net>, while sites like <www.e-patra.com> and <www.rediff.com> offer e-mail in some regional languages also.

CONCLUSIONS

The advent of Internet as a medium of mass communication poses numerous opportunities, challenges and dilemmas for mental health professionals. It is necessary for all mental health professionals, especially those in the developing countries, to remain informed on the latest developments in this area, so that they are able to derive maximum benefit from the opportunities offered by this exciting medium.

COMPETING INTERESTS

The author owns and edits PsyPlexus <www.psyplexus.com>, a portal for mental health professionals.

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