Academic Psychiatry 24:168-172, September 2000
© 2000 Academic Psychiatry
Computers in Psychiatry Today
Jennifer Bremer, M.D. and
Eugene V. Beresin, M.D.
Dr. Bremer is at The University of Chicago, Chicago, IL; Dr.Beresin is Director, Child and Adolescent Psychiatry Residency Training, Massachusetts General Hospital and McLean Hospital, and Associate Professor or Psychiatry, Harvard Medical School. Address reprint requests to Dr. Bremer, Dept. of Psychiatry, Univ. of Chicago, 5841 S. Maryland Ave., MC 3077, Chicago, IL 60637. e-mail: BREMERMI{at}aol.com
Key Words: Computers • Media Columns • Internet
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INTRODUCTION
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With its invasion into your patients' lives and the wealth of professional tools it offers, even computer-shy psychiatrists need to stay current with today's computer world.
Fortunately, some of the best front-line teachers about this ever-expanding e-universe could be in your office—they are your patients. As in other aspects of therapy, asking your patients to educate you about this aspect of their world has multiple pluses, and it benefits both patient and psychiatrist. The patient can be the expert—a special treat for the child patient—and you will learn about computers and be able to discover the patient's specific experience of the multifaceted computer world.
Supplementing this ongoing education, a basic awareness of computers will both allow you to guide your patient's use and use it personally to improve the clinical care you offer. Most Internet uses offer both vast possibilities and some hazards (1). Unfortunately, relatively few studies have looked at the impact of the computer on our patients or on psychiatric treatment.
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THE PATIENT'S COMPUTER USE
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Internet Socializing
Chat groups are virtual rooms online that one can enter anonymously to "talk" to faceless strangers via the computer screen. Some chat groups are subject-focused; some are organized, for example, around age-groups, dating, parenting, hobbies, sports, and politics, among other topics. According to the Pew Internet and American Life March Poll 2000, out of the approximately 90 million Americans connected to the Internet, 28%, or 26 million of them have participated in a chat room of some sort (Daily Internet Activities. Pew Internet and American Life Poll, March 2000. http://www.pewinternet.org/reports/reports.asp?Report=11&Section=ReportLevel2&Field=Level2ID&ID=5. June 6, 2000); 5 million reported using chat rooms daily (Internet Activities. Pew Internet and American Life Poll, March 2000. http://www.pewinternet.org/reports/reports.asp?Report=11&Section=ReportLevel2&Field=Level2ID&ID=7. June 6, 2000).
Chat groups can be useful for the socially phobic patient as a place to practice interacting with others. The anonymity may allow the anxious patient to feel safe practicing "talking." Chat groups also may be an uncontrolled source of inappropriate information for children. Also, chat rooms pose the danger of users' unknowingly interacting with online predators. Children have been lured and abused by sexual predators who contact them through chat rooms or via instant messages (Psychiatric News, May 5, 2000, p. 5). Detailed information about protecting children online is available at the FBI Library website (http://www.fbi.gov/library/pguide/pguidee.htm). Further information is also available at www.protectkids.com or in Donna Rice Hughes' book Kids Online, Protecting Your Children in Cyberspace (Revell, 1998). Online matchmaking services like Match.com must offer similar hazards to adults, as self-misrepresentation, be it intentional or by mistake, is so easy online. Without face-to-face impressions, those who wish to can easily create a false identity that may mislead others as to their true intentions.
Therapists have the opportunity and duty to warn patients and their parents of online threats and to educate them about how to stay safe online. It is important to educate patients not to reveal any personal information, especially identifying information. Real names, phone numbers, addresses, schools, towns, etc., should be avoided during Internet socializing.
Absorption in virtual chat rooms also poses the emotional risk of replacing real-life interactions and providing an unhealthy refuge. The patient may come to prefer on-line, rather than in-person, interactions (2). "Internet addiction" is discussed widely in the popular press. Although it is not a formal DSM-IV diagnosis, the behavior of addictive Internet use, according to various studies, is associated with significant suffering, decreased functioning, and with comorbid Axis I diagnoses (3).
E-mail is another means of Internet socializing. The convenience of e-mail may allow people with busy lives to stay in better touch. Fifty-nine percent of Internet users say that because of e-mail they now communicate more often with family members. In 55 percent of users, this increased communication has not only kept them in touch, but has even brought them closer to family members. These types of benefits are not just limited to family interactions, but are also reported in respect to friendships. A majority, two-thirds, of Internet users, say that e-mail has helped to bring them closer to friends (4; The Internet Effect. Pew Internet and American Life Poll, March 2000. http://www.pewinternet.org/reports/reports.asp?Report=11&Section=ReportLevel3&Field=Level3ID&ID=6. June 6, 2000).
E-mail's apparent impersonality allows some people to be more expressive and intimate than they otherwise would be. Friendships based on this paradoxical intimacy may emerge, which could be both beneficial as well as harmful, depending on the situation. As with chat rooms, increased intimacy on e-mail might benefit shy or socially inhibited persons. If they are able to "practice" interacting in a more protected setting, they may eventually become more comfortable and be able take some of those skills and confidence into face-to-face conversation. However, e-mail and online communication may become a problem if they prove an overused refuge from in-person interactions. Likewise, if e-mail communication becomes a replacement for real-life interactions and friendships, the danger of social isolation can arise.
Patients sometimes wish to contact their doctors by e-mail. This may be a useful and convenient manner for patients to keep the doctor better informed, to schedule appointments, or make requests for medication refills. However, being a physician online has hazards. One hazard to e-mail is its lack of privacy. Employers, for example, may legally read their employees e-mails, and e-mails may prove accessible to computer hackers. Warning patients of this lack of assured confidentiality before there is e-mail communication is crucial. Recommending that the patient use a computer outside of work for this type of correspondence is a good idea, and for extra protection, a method of encryption might be suggested.
Another shortcoming of e-mail is the possibility of misunderstanding the patient through typed communication. Without the benefits of facial expressions, body language, or tone of voice, emotions underlying e-mail communication may easily be misinterpreted because the subtle cues to what the patient is experiencing are absent. E-mail correspondence should not be used as a substitute for therapy. The face-to-face interaction between doctor and patient is crucial to developing and maintaining a therapeutic relationship. Emphasizing the importance of in-person meetings is necessary, especially for all critical communications, such as changes in symptoms or suicidality. Similarly, any important communications that the doctor has for the patient should be done in person. It is also difficult to assess the patient's understanding of instructions via e-mail. However, e-mail sometimes serves to supplement a patient's understanding by offering information in a personal, written document.
Information-Gathering
The opportunity to instantly gather vast amounts of information using one's home computer is a powerful resource. Information sources include an array of government sources, libraries, businesses, newspapers, groups and individuals. Patients have never had an easier way to access mental health information and to become educated consumers. Medicine-related websites have increased in number and are among the top 50 most visited sites. Fifty-four percent of Internet users say they have visited some type of medical website for health and medical information (Pew 2000). Much Internet information is accurate and scientific, such as the medical journal abstracts available on MEDLINE. All physicians should be aware of this tool so they can use it for free, up-to-date scientific journal searches on countless topics, as discussed below.
However, the Internet's enormity also ensures that there will be a supply of indecent material for children. Psychiatrists have the opportunity to remind parents that children's Internet surfing merits meticulous watching. Keeping computers in public areas with frequent parental observation is important. Some computer programs, such as Surfnet and the Net Nanny, are also available to help block out "child-inappropriate" material and give parents more control over what their children see. However, these programs all have limitations. John Ryan, associate general counsel at America Online, Inc., recently testified that "the best filtering software could not cover the scope of the Internet..." (Psychiatric News, May 5, 2000, p. 5). Computer use by children should be screened just like TV or books. In fact, Internet use merits even closer scrutiny because of the interactive possibilities it provides.
Reminding patients about the possibility of professional-sounding misinformation online is also important. There is nothing to "prevent an unqualified entrepreneur from putting out a shingle as a mental-health expert" (5). Patients should be reminded to take disconcerting or confusing mental health information found online to you or another health professional for review and discussion. Patients should also be informed of the more reliable websites so they may take advantage of them to find accurate information. For example, the American Psychiatric Association's (APA's) and American Academy of Child and Adolescent Psychiatry's (AACAP's) websites offer information sheets for patients and their families (APA at http://www.psych.org and AACAP's at http://www.aacap.org).
The website of the National Alliance for the Mentally Ill (NAMI) may also be of use for patients (http://www.nami.org). It offers not only information about a host of mental illness subjects but also information about locations and times of support group meetings.
Computer Games
Bonuses to computer game use include the many educational programs available offering entertaining, interactive ways for children to learn (6). Fine-motor skills also can be practiced in games demanding coordination. Other games challenge intellectual reasoning, and certain games have even been shown to develop information-processing skills (7). Computer games have even been developed to help combat mental disorders. Although not controlled, one intriguing study found that a game teaching relaxation skills through biofeedback improved half of the studied patients' irritable bowel syndrome most of the time (8).
The primary dangers of computer game-playing, a seemingly harmless pastime, include children's exposure to inappropriate games and loss of time from other real-life activities. Some games are excruciatingly realistic and violent. These may add to a child's fears, especially those children with anxiety symptoms. Such games theoretically may also feed violent impulses, especially in the child who tends to act out. Little research has been done to date concerning children's and adolescents' use of the Internet and possible behavioral repercussions, but concerned parents and professionals are starting to look for ways to help avoid negative impact. Better programming, stricter regulation by parents, and media education at home and in the schools may help avoid negative impact of computer games (9).
Time spent playing computer games also may subtract from time socializing with others. Social skills may suffer, especially in those with existing interpersonal difficulties. Other productive activities, including work or studies, also may suffer as children spend more and more time playing games. Young children's physical health also may suffer as a result of excessive time on the computer. The physical inactivity of computer time inevitably contributes to the increasing weight problem in today's children (10). Instead of participating in sports or other physical activities, many children sit indoors in front of the computer screen.
Organization
The computer also might offer help for individuals with neuropsychiatric disabilities. Theoretically, it could help those suffering from attention deficit hyperactivity disorder, although research is lacking. Through word processing, the organizationally deficient patient may be able to produce better work assignments. For example, word processing allows a person to jump from one part of a paper to another, helping those whose work tends to be nonlinear. Some scheduling programs include reminder alarms, which might help the distracted or disorganized patient remember appointments and other important dates. The hand-held organizers like Palm Pilot even make these computerized organization devices portable. The pitfalls here are those of a computer-reliant world of users who become inefficient when the computer crashes.
An array of "homework help" sites are also available online and may help the academically troubled child. These sites, as all other types of sites, vary in quality and the help offered. One site offers not only "bulletin boards" where homework questions are posted and answered but also the locations of educational computer games and information about college information fairs (http://www.startribune.com/education/homework.shtml).
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THE PSYCHIATRIST'S COMPUTER USE
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MEDLINE
An immense amount of information is available online that can be an invaluable resource for those who use it carefully. MEDLINE, the physician's and researcher's journal search engine, can provide an easy way to upgrade the care one gives patients. MEDLINE is available free of charge at multiple sites, including the National Library of Medicine's Internet Grateful Med site (http://igm.nlm.nih.gov) and PubMed (http://www.ncbi.nlm.nih.gov/PubMed). The speed with which literature searches can be done with this tool allows one to gather scientific data in minutes. MEDLINE allows the psychiatrist to stay more current about treatment than memory and time constraints would otherwise permit. Several related search engines can supplement this tool, such as AIDSline and Toxline.
The shortcoming of MEDLINE is that often only abstracts are available online for free. If abstracts are used alone, and carelessly, poorly conducted studies mistakenly might be used to guide treatment. If MEDLINE is used thoughtfully and is supplemented with full-text articles, however, it is a very valuable tool. Most journals, including the major psychiatric journals, also have their own online sites where psychiatrists can often find full-text article copies from the current and past journal editions, as well as information on current topics in the field.
It has been shown that those who obtain formal training in how to use MEDLINE effectively tend to use it more often (11). Thus, we recommend a formal library course to learn proper use of the search engine.
Other Useful Internet Sites
Psychiatrists can take advantage of the American Psychiatric Association's (APA's) and American Academy of Child and Adolescent Psychiatry's (AACAP's) websites to obtain a wealth of resources for both themselves and their patients. These sites offer practice guidelines and information on current research, meetings, awards, and fellowships (APA at http://www.psych.org and AACAP at http://www.aacap.org). Subscribers can find the APA e-mail news service at www.psych.org/apamember/onlinenews.html. Psychiatrists can also receive the AACAP listserve, which notifies individuals of award information and special AACAP functions. Many other associations offer valuable websites. The American Medical Association (AMA) website, for example, offers not only further information for patients, but also includes meeting information, an online bookstore, and several full-text journals (see http://www.ama.assn.org).
Listings of other psychiatric or mental health websites can also be found online, including the Hardin Meta Directory (http://www.arcade.uiowa.edu/hardin-www/md-psych.html) or can be obtained via the University of Michigan (http://www.psych.med.umich.edu/web/psychRef). Listing the vast resources available is beyond the scope of this column.
Of interest to trainees, the Interactive Testing in Psychiatry (ITP) site offers practice board-style questions (http://www.med.nyu.edu/Psych/itp.html). Information about the Boards, moreover, is available at the website of the American Board of Psychology and Neurology (http://www.abpn.com). The American Association of Directors of Psychiatric Residency Training website (www.aadprt.org) includes bulletin boards for residency positions and information about psychiatry training programs.
For those who have completed training, the Internet offers a way to continue one's education. For instance, the University of South Dakota offers a free education program at www.horizonseries.com. Continuing medical education credit can be earned online in a variety of ways, including at the ITP site and through virtual meetings online.
Assessments
Computers could also have a role in supplementing patient assessments. There are data that suggest efficacy and cost-effectiveness of using computer-assisted assessments. One study found such computer assessments to be as effective as traditional narrative clinical assessments and a form-style clinical assessment, and only 20%–45% as costly (12). Other studies further support the use of computerized screening for psychiatric disorders in outpatient community health clinics as being both effective and liked by patients (13–15). Computer histories might be effective in augmenting traditional histories. One study found that most inpatients who completed computer histories revealed several items unknown to the clinicians that were of importance (16).
Of course, there are inevitable pitfalls to using such computer assessments. The loss of information gained by personally assessing a patient and the loss of an opportunity to nurture a new relationship with a patient are two potential drawbacks to using computerized assessment. Moreover, some data suggest that older, less educated patients may avoid computer assessments (17). An upcoming column will further discuss the role of the computer in the patient/psychiatrist relationship and online psychiatric treatments.
Of note, computer education programs have been tried in inpatients with long-term psychiatric illnesses with some success. Some patients have utilized vocational programs, and others have focused on basic general education (18). Another study found that a computer-based violence-prevention intervention program may be useful for young adolescents (19). Such computer education tools certainly merit further study with clinical populations.
In summary, an awareness of the vast power of computers to both affect patients' lives and improve the treatments offered is essential for today's psychiatrists.
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ACKNOWLEDGMENTS
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The authors acknowledge the valuable assistance of Sarah Hall in the preparation of this manuscript.
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REFERENCES
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- Bremer J, Rauch PK: Children and computers: risks and benefits. J Am Acad Child Adolesc Psychiatry 1998; 37:559-560[CrossRef][Medline]
- Pratarelli ME, Browne BL, Johnson K: The bits and bytes of computer/Internet addiction: a factor-analytic approach. Behavioral Research Methods and Instrumental Computing 1999; 31:305-314
- Shapira NA, Goldsmith TD, Keck PE, et al: Psychiatric features of individuals with problematic Internet use. J Affect Disord 2000; 57(1-3):267-272
- "Protect Children From Predators On Internet," Parents Tell Congress. Psychiatric News May 5, 2000: pp. 5, 66
- Almer, E: Online Mental Health Services: An Opportunity, or an Alarm? The New York Times, April 22, 2000
- Blake J, Goodman J: Computer-based learning: games as an instructional strategy. ABNF Journal 1999; 10:43-46
- Yuji H: Computer games and information-processing skills. Percept Mot Skills 1996; 83:643-647[Medline]
- Leahy A, Clayman C, Mason I, et al: Computerized biofeedback games: a new method for teaching stress management and its use in irritable bowel syndrome. J R Coll Physicians Lond 1998; 32:552-556[Medline]
- Strasburger VC, Donnerstein E: Children, adolescents, and the media in the 21st century. Adolesc Med 2000; 11:51-68[Medline]
- Luepker RV: How physically active are American children and what can we do about it? Int J Obes Relat Metab Disord 1999; 23(suppl 2):S12-S17
- McKibbon KA, Haynes RB, Johnston ME, et al: A study to enhance clinical end-user MEDLINE search skills: design and baseline findings. Proceedings of the Annual Symposium on Computer Applications to Medical Care 1991; pp 73-77
- Yokley JM, Coleman DJ, Yates BT: Cost-effectiveness of three child mental health assessment methods: computer-assisted assessment is effective and inexpensive. Journal of Mental Health Administration 1990; 17:99-107[Medline]
- Carr AC, Ghosh A: Response of phobic patients to direct computer assessment. Br J Psychiatry 1983; 142:60-65[Abstract/Free Full Text]
- Kobak KA, Taylor LH, Dottl SL, et al: Computerized screening for psychiatric disorders in an outpatient community mental health clinic. Psychiatr Serv 1997; 48:1048-1057[Abstract/Free Full Text]
- Kobak KA, Greist JH, Jefferson JW, et al: Computer-administered clinical rating scales. a review. Psychopharmacology 1996; 127:291-301[CrossRef][Medline]
- Carr AC, Ghosh A, Ancill RJ: Can a computer take a psychiatric history? Psychol Med 1983; 13:151-158[Medline]
- Spinhoven P, Labbe MR, Rombouts R: Feasibility of computerized psychological testing with psychiatric outpatients. J Clin Psychol 1993; 49:440-447[Medline]
- Brieff R: Personal computers in psychiatric rehabilitation: a new approach to skills training. Hosp Community Psychiatry 1994; 45:257-260[Abstract/Free Full Text]
- Bosworth K, Espelage D, DuBay T: A computer-based violence prevention intervention for young adolescents: pilot study. Adolescence 1998; 33:785-795[Medline]
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INTRODUCTION
THE PATIENT'S COMPUTER USE
