How to evaluate health and mental health sites on the internet

[David Baxter PhD]

Are irreputable health sites hurting your patients?
Psyber Psychiatry, Vol. 5, No. 12 / December 2006
by Richard A. Montgomery, MD
Private practice, Sage Health Care, Boise, ID

'NO BASH' recalls 6 questions to ask when surfing.

Web sites that offer questionable information about psychiatric illnesses and treatments can sway patients toward unproven, often worthless ?remedies.? These sites may present themselves as patient resources but instead are promoting political or antipsychiatry agendas or selling unregulated, untested therapies.

Don?t let unscrupulous sites fool your patients. This article offers tools to help patients find evidence-based mental health information from objective, reputable sites.

Why counsel patients on web use?
Bad information can be harmful. I have lost many patients to follow-up because they discovered an unsubstantiated treatment complication or off-the-wall ?remedy? on an antipsychiatry or antimedication site.

Years ago, I treated another mental health clinician. After she viewed an antimedication site, she was convinced that her bipolar disorder had ?run its course? and stopped treatment, even though she had suffered a severe manic episode 1 year earlier. Another doctor treated her as if her bipolar disorder had been ?cured.?

I resolved never to let patients troll the Internet for medical information without rudimentary guidance.

Most patients do not know how to analyze medical information. In medical school we learned?by implementing dictums of evidence-based medicine?where to find clinical information and how to assess its quality and objectivity. Most patients have not received such training.

Patients need our support. Most patients seeing a psychiatrist for the first time are anxious and fearful of what they might find out about themselves or their lives. Exploring their inner worlds is routine to us, but unsettling and disorienting to them. Unfiltered, uncensored Web sites prey upon new patients by offering a ready source of comfort.

Guiding new patients during this vulnerable time can cement the doctor-patient relationship and prevent faulty information from jeopardizing recovery. Patients who do not receive emotional support could turn to a Church of Scientology site?such as http://psychiatrysucks.com?or one of many other antipsychiatry sites to fill the void.

Encourage patients to describe their anxieties and trepidations toward their illnesses and medications. Help them explore questions about trust and hope, and anticipate and solicit questions resulting from their Internet exploration.

Setting web search guidelines
When new patients ask where to find information on their disorder or treatment, suggest the National Institutes of Health?s Web site, (www.nih.gov), which offers a wealth of current information written in plain English, and links to databases, such as Medline and ongoing clinical trials.

Then give patients basic guidelines for broader Internet exploration. Warn them against sites that post personal attacks, exude a zealous tone, or present extreme positions or statements. Sites infused with fervor?positive or negative?should always warrant suspicion.

For more subtle concerns about quality of information, encourage patients to ask the following six questions?easily recalled with the acronym NO BASH (Table)?when visiting a mental health site:

NO BASH: 6 questions to ask when perusing a health site

1. Is the site Networked?
   
2. Is the information Objective?
4. Is the content Balanced?
6. Does the site?s author make Accusations?
8. Is the site Selling something?
10. Is the site 'Hyperholy'?

IS THE SITE NETWORKED?
Truth is our currency in medicine, so reputable operators whose sites promote widely accepted, evidence-based information have no problem hyperlinking their sites to others that promote different ideas. By contrast, sites that push an agenda or promote ideas outside the mainstream usually do not hyperlink to opposing viewpoints.

IS THE INFORMATION OBJECTIVE?
Sites that editorialize one viewpoint while excluding others generally offer suspect and often invalid information. By contrast, sites that present two or more sides to a particular topic usually are less biased.

Although objective, unbiased presentations of referenced information about illnesses are considered ideal medical resources, personal accounts of struggles with mental illness also can empower and inspire patients and should be evaluated on their own merit. Also invite patients to discuss their experiences.

IS THE CONTENT BALANCED?
Steer patients toward mental health sites that offer understandable and comprehensive information about an illness, including:

• symptoms
  
• full DSM-IV-TR diagnostic criteria
  
• epidemiology
  
• risk factors
  
• all available pharmacologic and psychosocial treatments with efficacy data for each treatment
  
• the disorder?s natural course vs. expected treatment outcomes
  
• a brief differential of related or similar diagnoses.

Sites that promote specific agendas often emphasize some of these elements while de-emphasizing others. Sites promoting alternative therapies, for instance, might not explain all available treatment options and associated efficacy data. One site sells telephone psychotherapy as monotherapy for bipolar disorder without mentioning medications.

DOES THE SITE?S AUTHOR MAKE ACCUSATIONS?
Some sites cast blame for an illness or treatment outcome on psychiatrists, psychologists, organizations, cultures, or other entities, and offer unfamiliar approaches to diagnosis and treatment. Such sites should raise a red flag.

IS THE SITE SELLING SOMETHING?
Pharmaceutical companies, a major presence on the Web, provide largely accurate information about disease risk factors, symptoms, epidemiology, and treatment options. These companies, however, selectively present and interpret data when describing the efficacy of their products. Although drug manufacturers legally cannot make false claims about their products, advise patients to use these sites solely for general information about a drug and to disregard claims about efficacy.

Other sites follow seemingly up-front information about an illness with a sales pitch for a treatment. The information is often slanted to make the product more appealing.

Again, help patients scrutinize the information and recognize soft-sell tactics. For example, some sites post bogus or vague author credentials, or are designed to resemble a clinical journal to appear authoritative.

Finally, many treatments sold on the Internet are not FDA-approved or regulated. Thanks to advances in Web technology, sites promoting unproven treatments can look professional and authoritative, so that even Web-savvy patients cannot discern a proven therapy from ?snake oil.?

Warn patients to be suspicious if a prescription is not required?especially if the product is ingestible.

IS THE SITE ?HYPERHOLY??
For some patients, an integrated approach to healing employs spiritual as well as biological and psychosocial components. Through Web portals, overzealous organizations try to exploit patients? spiritual needs by force-feeding religious dogma as a singular pathway to mental health?while ignoring biologic models for disease and recovery. Help patients recognize sites that present spiritual information in this manner.

Other considerations
Also consider the site?s domain designation:

• sites with the .edu domain?operated by educational institutions?are most reliable
  
• .com designates a commercial site that is generally geared to selling goods or services and might or might not support psychiatric treatment
  
• .net and .org sites tend to be noncommercial, although some might be antipsychiatry.

Also steer patients to health care sites that display the HON Code seal of the Health On the Net Foundation (HON). HON, a nonprofit international organization that promotes development of useful, reliable online medical and health information, certifies health sites that meet its rigorous ethical standards (see www.hon.ch/HONcode/Conduct.html.