The Internet provides access to numerous information and resources on illnesses, diseases, health products and services. It provides online access to diagnoses, therapies, drugs and various types of treatment. Through forums and social media, individuals may share experiences, worries, problems and solutions with people around the world. Pharmaceutical and medical device industries, patient organizations, health institutions, health research institutions and even governments use this tool to build relationships with the public, promote their products, services, ideas and values.

Research on the use of Internet in health-related domains has evolved significantly over the past ten years. Concerns expressed by researchers at the onset of the widespread dissemination of this communication technology have given way to more nuanced analysis. For instance :

• While there was concern for the quality of information disseminated on the Internet, it is now recognized that many sites are designed by credible and informed healthcare players; that evidence-based information, once restricted to academics, is now accessible to all; that the public is becoming more critical of information found on the Internet and continues to make use of multiple sources of information.

• There was concern that the Internet would affect negatively the relationship between patients and doctors. Researchers are now able to provide more nuanced observations.

• There was also concern about the dangers of online direct-to-consumer sales of drugs and other complex and risky health products. Again, without denying these dangers, researchers have developed a better understanding of the scope of health-related web sites and they have brought some nuances to the image of “reckless consumers totally deprived of critical judgement”.

Thus, now that the Internet is well rooted in our habits, what exactly do we know about it and what do we do with it? We invite you to listen to our interview with Sally Wyatt, professor of digital culture at the University of Maastricht, on the use of Internet in health, and Marc Lemire on patients’ responsibilities toward direct-to-consumer sales of drugs online. Among our collaborators in this dossier, we also count on Martin Lasalle, journalist for PasseportSanté.net. In a very enlightening lecture, he presents the other side of the story by explaining how journalists communicate health issues to the public. Christine Thoër, from the Media and Health Research Group, presents a nuanced perspective of the impact of Internet on the doctor-patient relationship. Finally, Christopher Herbert, Ph.D. candidate at the Department of Psychiatry at McGill University, discusses the potential of Internet in the field of mental health.

We hope you enjoy your visit! Your comments on an entry or the entire dossier are always welcomed!

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The Internet as a credible source of information on mental health?

A recent study shows that 61% of American Internet users sought information on their health or that of a loved-one on the Web and up to 22% of them searched for information on mental health (Fox, 2009). Web-based information influenced 58% of American Internet users in their health-related decision-making (consultation, treatment), while three-quarters of users admit not checking the sources used by the Websites (Fox, 2006). Unfortunately, studies show that information on mental health available on the Web is not always of high quality. According to Bremner, Quinn, Quinn, and Veledar (2006), 75% of Web sites on trauma and anxiety disorders do not cite their sources, 42% of them post erroneous or incomplete information and 6% even present dangerous information. Given the fact that many Internet users determine the credibility of the information based on the Web site’s visual aspect, the language used and the ease of navigation (Toms & Latter, 2007), psychologists should be aware that imprecise or erroneous information does not only reach a very large audience, but also tends to be taken at face value.

The Internet as a diagnostic and referral tool?

Few people with mental health disorders consult mental health professionals (Wang et al., 2005). With its low operating costs and its capacity to make information available to the greatest number of people, the Internet, as a tool, has thus a significant prevention potential. From a public health perspective, early detection coupled with referral to local care structures may be beneficial.

While several Web sites post lists of mental health disorders symptoms, others go as far as providing an unofficial diagnosis by means of an online questionnaire. Although such sites may be extremely helpful, special attention should be clearly paid to the wording of unofficial diagnoses so as not to induce an adverse effect or provoke a severe emotional reaction in the absence of a professional capable of intervening. The questionnaire provides only a tentative diagnosis in the form of a suggestion; an official diagnostic can only be obtained from a trained professional. Where possible, a differential diagnosis should be included. Furthermore, the individual should be urged to obtain a confirmation of this diagnosis from a trained professional.

Online interventions?

Online therapies may be conducted by various means, including e-mail, videoconference or real-time text. Studies about online treatment of post-traumatic stress disorder, for example, demonstrate a significant reduction of symptoms, as well as the presence of a strong therapeutic alliance and a low dropout rate associated with these therapies (Knaevelsrud & Maercker, 2007). The effects of this therapy seem to be maintained over time, since symptom reduction remains even a year and a half later (Wagner, 2007). Nevertheless, users of such therapies may complain about the lack of human interaction (Lange et al., 2003). Studies involving graduated exposure in the form of virtual reality (Gerardi, Rothbaum, Ressler, Heekin, & Rizzo, 2008) are also being carried out, though this line of research is currently limited to case studies. Adapting virtual reality to certain traumatic situations that are more complex or personal may require further research and development.

Studies show that online therapy is more effective than wait list or supportive therapy, though other findings must be published before one can determine the effectiveness of online therapy compared to more classic and established approaches (Knaevelsrud & Maercker, 2007). One potential limitation is that the Internet may not be appropriate for all forms of therapy (e.g. psychodynamic therapy). Furthermore, these Internet-based approaches to therapy must also meet the ethical standards of the Canadian Psychological Association.

Conclusion

The field of mental health is faced with numerous challenges, several of which the Internet may be able to meet, at least in part. Today, patients and their loved ones can benefit from information, advice, preliminary diagnosis and referral services and even online therapy. These resources will probably become more and more available in the years to come. While these developments are viewed as positive advances, they can also adversely impact the mental health of Internet users if their quality is poor. International certification is one way to mitigate such risks and is becoming the norm (www.hon.ch).

Psychologists should ensure that the information available on the Internet is of high quality in order to achieve a positive impact. The Internet should not be a substitute for existing practices; instead, it should be used in combination with them as a complementary tool. Though the Internet offers new possibilities, it also offers new problems to solve (effectiveness of approaches, biases, the danger posed by poor practices, etc.). Should the mental health professionals rise to the challenge of addressing some of the limitations of Internet-based information and interventions, the Internet may offer a powerful new tool to reach larger numbers of people in need of treatment.

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An addiction without drugs

If researchers still disagree on a common definition of cyberaddiction, there is a consensus that it is a form of behavioural addiction such as an impulse control disorder.

Cyberaddiction can be defined as a psychological disorder leading to an irresistible and obsessive need to play a video game or use the Internet. According to some psychologists, cyberaddiction can also be one of the symptoms of other life problems, where the use of Internet is a way to escape reality.

Therefore, cyberaddiction shares common points with addiction such as the psychologist Marc Valleur defines it. According to him, it is characterized by

Even if the addictions can be from different sources, there are some common points between them:

• Loss of control related to a behaviour;

• Continuity of the behaviour despite negative effects;

• Intent to reduce or stop the behaviour without achieving it alone;

• Need to increase the doses to get the same effect as in the beginning;

• Presenting withdrawals symptoms (edginess, insomnia…).

According to some experts, cyberaddiction relates to four fields:

Video games of action and adventure;
Gambling;
Pornography;
Virtual relationships (friendly or romantic).

But a lack of consensus also appears when it is time to diagnose cyberaddiction. However with time and the way in which Internet has become part of everyday life, the criteria for diagnosis are more numerous than when researchers started to study the subject (see following box).

To treat cyberaddiction, it is possible to follow a psychotherapy or a cognitive behavioural therapy. There are also virtual clinics offering online treatments. But we can wonder what the quality of such a treatment is, considering that it is necessary to go on the Internet to treat an Internet addiction problem. However, in some countries like France, Taiwan and the Netherlands, a few hospitals and clinics are interested in the problem and offer treatments to patients with Internet and video game addiction symptoms.

If you want to learn more on cyberaddiction, we invite you to look at our dossier. You will find interviews with the psychologist Kimberly Young, the video game designer Louis-Martin Guay and the director of the organization Action Innocence France Véronique Fima-Fromager.

	What do you think? Should we worry about this new trend? Can cyberaddiction be hiding a deeper social malaise?

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If some researchers believe cyberaddiction is a new form of addiction without drugs, other specialists are convinced that we should not become alarmed if our teenager spends too much time in front of the Internet or playing video games. Véronique Fima-Fromager, the director of the organization Action Innocence France, gives us her opinion on cyberaddiction and tries to throw light on this new trend for the benefit of worried parents.

		What is the mission of the organization Action Innocence?
		“Action Innocence is an NGO founded in 1999 in Switzerland and in 2003 in France. Its mission is to contribute to preserve the dignity and the integrity of children on the Internet:   Action Innocence activities include: Prevention in schools by psychologists, for children, teenagers, parents and professionals; Awareness campaigns in the medias; Fighting child pornography file trafficking, in collaboration with police services in Europe. ”
		What do you think of cyberaddiction?
		“ According to some specialists, of whom Action Innocence shares the viewpoint, it is better to avoid speaking of video game addiction during adolescence. Indeed, at this age, everything can change quickly.   Excessive game usually disappears at the end of adolescence. When it is persistent, it is always the sign that the teenager is suffering in his personal life (such as heartbreak, violence at school…) or at home (divorce, house moving…). In a few cases, it can be the sign of a personality disorder (depression, psychosis).   Before being alarmist, it is necessary to try to evaluate to what extent the child puts himself in the virtual worlds: is the use temporarily excessive or has it become effectively pathological?  Does he play for pleasure or to avoid displeasure?   In this evaluation, it is important to consider the global time spent in front of screens whatever they are (television, computer, video game…).   It is also necessary to consider school results, the lack of other occupations (such as sport), social isolation and the regular use of toxic substances like tobacco, hashish or coffee. ”
		What would you suggest to parents worrying about the use their children are making of computer and Internet?
		“ Video games… While excessive play of video games can be damaging to the development of a teenager, it can also be used to develop some abilities. Everything depends on the game.   The idea is not to hide the risks of these games but to keep an objective approach. Too often, video games are a source of misunderstanding for non-players. Many teenagers complain that they cannot speak about the games they like with their parents. However, it is essential to set up a family dialog around this leisure activity.   The role of parents is to limit the time spent playing, introduce a contract and to make sure the family respects it. Children do not have control over their impulsions and cannot stop by themselves, even if they want to. For the same reason, it is better to cut Internet access at night.   But parents must also show their interest in the games their children play by asking questions or even cheering them on their success. When the player talks about the story of the game, he learns how to stand back, express and share his emotions. If there is a problem, it is always possible to see a specialist.   In addition, some games are extremely violent. This is why it is recommended, before buying a game, to check if it suits the age of the child. These virtual worlds can quickly create a form of addiction, if only for their time-consuming aspect. It is the role of parents to set rules to supervise their use.   The Pan European Game Information classification system exists to help buyers find the game that suits them, according to their age. In France, a group of institutional, professional and associative partners created PédaGojeux, an informative website on video games and their use. The objectives are 1) to increase public awareness of the issues of child protection and the appropriate use of video games; and 2) to provide parents with educational approach around the video game problematic.   Computer and Internet in general These recommendations are also applicable to the use of Internet in general by children and adolescents. It is the role of the parents to set limits with their children and to show them how to use the Internet. Nowadays, digital education must be part of general education. ”
		Do children and teenagers sometimes worry?
		“ It is surprising to see teenagers talking between them of cyberaddiction. They are sharp on this matter and do not hesitate to qualify the more addicted of “NO LIFE”. However they are not necessarily preoccupied, neither aware of the time they spend in front of the computer. More and more admit getting up at night to chat or play…without being considered cyberaddicted. Some of them are also able to distinguish between schooltime and vacation time, when they usually spend more time in front of the screens. ”
		What are the next prevention activities you plan to organize?
		“ Action Innocence carries on its activities in schools. We are thinking of developing new prevention modules to follow the evolution of the use of new technologies by children and teenagers.”

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