E-mental health: A medium reaches maturity

It does not seem to have taken that long for the Internet to have gone from a hobby on the fringes of society in the early 1990s to today's ubiquitous system that affects many elements of people's lives, including their mental health. A search for “Internet” in the archives of the Journal of Mental Health unveils a significant rate of change in prevailing attitudes and illustrates the rapid evolution of the network. Mentioned less than a dozen times in all the issues prior to 2001, Killick's (1996) “News and Notes” section sounded a cautiously optimistic note for the provision of information, connection to peers and healthcare professionals, and even video conferencing and computerized interventions. However, it also referred to the extensive technical barriers that existed at the time (Killick, 1996). As predicted, the provision of high-quality information online has been at least partially realized through the increasing quality of mental health information on centralized services such as NHS Choices (e.g. http://www.nhs.uk/conditions/Self-injury/) as well as more open resources such as Wikipedia (Reavley et al., 2011). Service users today have unparalleled opportunities to connect with one another and gained benefit from sharing (Wicks et al., 2010, 2012), and computer-guided therapies such as “Beating the Blues^®” are recognized as providing significant clinical benefit (Foroushani et al., 2011).

A few years later, at the turn of the millennium, Gournay (2000) added that the Internet could potentially provide “consumers and their families … a much greater say in what happens to them in services”. It is less clear where we are with respect to this assertion, though online initiatives such as the “e-patient movement” (Ferguson & Frydman, 2004; http://www.e-patients.net) can clearly complement real-world service user initiatives. Similarly, groups such as Patient Opinion (http://www.patientopinion.org.uk/) are permitting service users to let their views be known publicly, with responses from the managers responsible for their service provision.

Over a decade ago, the methods described in these pages (Oravec, 2000) to connect service users with one another and, potentially, with healthcare providers, such as email, chat rooms and online bulletin boards, remain familiar today. Since then, however, the march of social networks and the participatory “web 2.0” have upgraded Internet users from consumers into contributors in ways that many have wanted as mental health service users. Oravec also provided insightful cautions on the implications of the Internet for professional practice that still ring true, such as the lack of identifiable social cues in email, technological access and competency creating a “digital divide”, and concerns around confidentiality, validity of data and privacy. Since then, new issues have arisen too, such as pro-eating disorder websites, which may give users the feeling of a support group, but with potentially harmful consequences (Rouleau & von Ranson, 2011).

In this issue, Moessner and Bauer (2012) described an online system in Germany for individuals with eating disorders which used email and/or moderated forums to provide counseling. User satisfaction was high (82% would recommend to a friend with similar problems), and importantly, half of those who had not used any form of professional support before, using the online service subsequently sought professional care.

From a research perspective, in the early 2000s, Warm et al. (2002) demonstrated the potential of the Internet to access groups of individuals for research that would otherwise be difficult to acquire in significant numbers. By posting a call for participation in a number of online forums dedicated to self-harm, they were able to rapidly attract a sample of 243 respondents located around the world and gain insights into dissatisfaction with medical services treating self-harmers. A recent review (Swan, 2012) suggests that in addition to providing a pool for research participants, online research platforms also provide opportunities to conduct longitudinal studies, collect data from sensors or even genetic samples, and, for service users themselves, to design and execute research studies to better understand themselves, a group or an intervention.

In 2003, a special issue on stigma listed a number of online resources (Penn, 2003), so beginning a regular “website review” section in the journal featuring links to high-quality online information resources including chronic fatigue syndrome (Lipczynska, 2005a), eating disorders (Lipczynska, 2005b), social anxiety (Lipczynska, 2008) and suicide (Lipczynska, 2009), among others. Today, links to high-quality sources of information remain important, and mental health charities such as The Samaritans use social networks such as Facebook as a means of outreach to the community (https://www.facebook.com/samaritanscharity), as well as to raise awareness. A Google search for “suicide” in the UK prompts an immediate link and telephone number for The Samaritans above other search results, providing an example of support services finding service users where they are, rather than needing to be sought out to provide support.

In 2007, Bell prompted a re-evaluation of what the Internet is and what it can be with regard to mental health. In addition to reviewing the literature on the Internet in mental health up until that point, he made several important critical refutations (Bell, 2007). First, as a medium, he rejected the notion of there being a “psychology of the internet (no more than there is a ‘psychology of radio waves’…)”. Second, he rejected any reductionist notion that the Internet per se can be either “good or bad for mental health”. Third, he rejected (and has continued to reject) the faddish diagnosis of “internet addiction”, noting that it would be preferable to address the behavior (such as gambling) rather than the medium. Bell's perspective as a mental health researcher and a practitioner is informed by his experience as a participant and online citizen through blogging about psychology (http://mindhacks.com/author/vaughanbell/), referencing mental health topics on Twitter (https://twitter.com/#!/vaughanbell) and contributing to mental health articles on Wikipedia (Wicks & Bell, 2012).

Writing as a person with depression in 2010, Groot (2010) described a self-developed system that permitted continuous self-assessment and monitoring of his mood in order to journal periods of worsening and recovery and to evaluate perceived treatment efficacy. Such a project can be classified as part of what is now referred to as the “Quantified Self” movement, and an increasing number of tools are becoming available to support individuals who wish to use them (Swan, 2012). In Groot's case, the sheer density of the data is quite incredible (a 0–10 self report scale completed every day for several years), and new n = 1 statistical techniques may be needed to be developed to deal with and aggregate such rich data sets on a larger scale to answer interesting research questions at the group level – like whether climate has an impact on daily mood, for instance (Bauer et al., 2009). In this issue, Bauer and Moessner (2012) (also from Germany) described further developments in patient self-monitoring including how it can be specifically built in to care plans. Importantly, both inpatients and outpatients use the same system, with email reminders sent to them at pre-defined intervals and the option to enter data via a mobile device. Bauer and Moessner (2012) suggest the benefits are not just an improved level of support for users, but, once an outpatient, greater feedback for health care providers as to the individual's need for further support.

There are things we see today that were not predicted, however. In this issue, Fernández-Aranda et al. (2012) described the evolution of a ‘serious game’ (PlayMancer) (trialed in Spain) which takes elements of personal therapy and supplements them with game-like elements and biofeedback technology. The authors argued that the nature of video games (i.e. they are intensive, promote concentration, are immersive and are engaging to use) combined with physiological reactivity and emotional recognition can create novel therapeutic opportunities. For instance, biofeedback sensors can identify areas of the game that a user finds difficult or stressful and react to support their emotional reactivity and provide coping styles in a low-pressure and replicable environment. Also, in this issue, Musiat et al. (2012) from the UK describes the potential for fully automated systems which draw on many of the elements already discussed (i.e. patient-reported health information, sensors and use of computers) to provide tailored feedback to users without human intervention. Although there are psychometric and statistical caveats to be taken into account, the authors proposed that several levels of feedback can be developed for computerized systems – from normative feedback (“Here's how you compare with others like you”) to summative feedback (“You drank 30 units of alcohol this week”) and finally to ipsative feedback (“You've improved your rate of compulsive thoughts this month”).

As a relatively young field of research, there remains much rigorous work left to be done to evaluate the potential of systems such as these (not to mention those that currently only exist as an idea in the mind of a researcher, service user or application designer). It is also a challenging field in which to work. In parallel to the systematically developed programs developed here, the volume of third-party systems in the world that exist as video games, social network tools or mobile phone applications (apps) is expanding at an exponential rate – and these are not developments which are gated by funding or ethical review committees. One thing seems certain, in order to understand mental health problems in the context that service users (particularly young adults and adolescents) experience them, the field must pay closer attention to developments online and make time to participate and engage in the connected world. If we do that, we are bound to have another interesting decade ahead of us.

Conflict of Interest: P.W. is an employee of PatientsLikeMe and owns stock options in the company. PatientsLikeMe has received research support from Abbott, Accorda, Avanir, Biogen, Genzyme, Merck, Novartis, Sanofi and UCB.