ABSTRACT

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In this article, the role of e-technology is explored, with an emphasis on the advantages
and disadvantages of its use for health care and mental health research. E-technology is
broadly understood to include the Internet and related information technologies, and
in recent years, its use has grown rapidly. The Internet is a major source of health in-
formation, and there is potential to deliver enhanced services through this medium. In
addition, e-technologys role in future mental health service delivery and research will
continue to expand as increased numbers of consumers, caregivers, health profession-
als, and the general population go online, particularly as the technology is rened and
made even more user friendly.
MICHELLE CLEARY, RN, BHlthSc(Nurs.), MHlthSc(Nurs.), PhD;
GARRY WALTER, MB BS, BMedSc, PhD, FRANZCP; AND SANDRA MATHESON, BSc(Hons.)
in Mental Health Services and
Psychiatric Research?
What Is the Role of

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42 JPNONLINE.COM
I
n this article, we explore the
role of e-technology, with an
emphasis on identifying the
advantages and disadvantages of
its use for health care, particularly
mental health care, and mental
health research. Although no for-
mal denition exists, e-technology
is broadly understood to include
the Internet and related tech-
nologies, such as digital and Web-
based television (Eysenbach,
2000). The Internet, the fast-
est growing e-technology in the
world, is a major source of health
information and has the potential
to deliver enhanced services. In
addition, e-technologys role in
future mental health service de-
livery and research will continue
to expand as increased numbers of
consumers, caregivers, health pro-
fessionals, and the general popu-
lation go online, especially as the
technology is rened and made
even more user friendly.
The most recent gures from
the Australian Bureau of Statis-
tics (2007) indicate that 64%
of households in Australia have
home Internet access, and 73%
have access to a home computer.
In the United States, half of its
households have computers, with
this percentage rising daily (Con-
stantino, Crane, Noll, Doswell, &
Braxter, 2007). Many more peo-
ple have access through schools,
universities, and workplaces.
The Internet has been found
to be increasingly used as a ma-
jor source of health informa-
tion (Baker, Wagner, Singer,
& Bundorf, 2003; Pennbridge,
Moya, & Rodrigues, 1999). Sev-
eral years ago, it was estimated
that approximately 20,000 Web
sites worldwide were dedicated
to health care (Dyer, 2001); no
doubt, that number is now much
higher. More recently, it has
been found that more than 10%
of the general population (and
more than 20% of those with
any history of mental illness) use
the Internet as a primary source
of mental health information
(Powell & Clarke, 2006). Be-
cause the Internet plays a signif-
icant role in mental health in-
formation seeking, and because
the rapid growth and facility of
the Internet to have widespread
inuence, e-technology is now
seen as a potential platform for
delivering health-enhancing in-
terventions and services, includ-
ing research, to its users (Bowen,
Horvath, & Williams, 2007;
Houston, Cooper, & Ford, 2002;
Simpson, 2005; Stjernsward &
Ostman, 2006).
Surprisingly, psychiatric nurses
have not written much about this
topic, and, therefore, we thought
it was important to encourage dis-
cussion about the pros and cons
of using e-health, particularly
in regard to research. The lit-
erature informing this article was
sourced from electronic searches
of the databases CINAHL, Ovid,
MEDLINE, and PsycINFO using
the terms computers, technology,
Internet, psychiatry, mental health,
and psychiatric nursing and from
examination of reference lists to
identify any relevant articles.
e-HEALTH AND e-MENTAL
HEALTH
The term e-health encompasses
the Internet and related tech-
nologies and aims to improve
health care by enhancing com-
munication pathways between
service providers and patients
(Eysenbach, 2001). The concept
of e-mental health refers to mental
health services and information
delivered or enhanced through
the Internet and related technol-
ogies (Christensen, Grifths, &
Evans, 2002, p. 3).
The potential use and appli-
cation of e-health and e-mental
health are wide ranging. For ex-
ample, given that families with
children are more likely than those
without to be using the Internet,
e-health can be useful in offering
online support for caregivers of
children with mental health prob-
lems (Scharer, 2005a, 2005b). On-
line support groups are also popu-
lar with people seeking assistance
for a range of problems, including
depression and substance abuse
(Finfgeld, 2000). In a sample of in-
dividuals with access to the Inter-
net, those with psychosomatic or
psychiatric disorders used e-health
more often than did those with
general medical problems (Havi-
land, Pincus, & Dial, 2003). For
some consumers, interacting with
a computer may be easier than in-
teracting face to face with mental
health staff (Farrell, Mahone, &
Guilbaud, 2004).
In the United States, a Web-
based home page portal with
communication, education, and
support features has been devel-
oped for mental health consum-
ers to improve their adherence to
treatment programs (Farrell et al.,
2004). Telepsychiatry is another
new technology used throughout
many rural areas in Australia.
One example of this is an extend-
ed e-mental health consultation
service with the purpose of im-
proving access to quality mental
health care for people in rural set-
tings (Neufeld, Yellowlees, Hilty,
Cobb, & Bourgeois, 2007).
Internet-based programs have
been shown to improve a range of
mental health problems (Grifths,
Farrer, & Christensen, 2007). In
one program in Perth, Western
Australia, e-health was found
to enhance depression recov-
ery (Robertson, Smith, Castle,
& Tannenbaum, 2006); the
program included e-consulta-
tions, psychoeducation, progress
monitoring, and evidence-based
therapy. Other potential benets
of e-mental health are exempli-
ed by the ndings of a 1-year
U.S. prospective cohort study
by Houston et al. (2002), which
examined the characteristics of
JOURNAL OF PSYCHOSOCIAL NURSING VOL. 46, NO. 4, 2008 43
Internet-based depression sup-
port groups. Those who used the
group were found to be socially
isolated and chronically de-
pressed but reported considerable
gains from the group; one third of
participants preferred online sup-
port to face-to-face counseling. It
seems the relative anonymity of
the Internet provides a forum for
concerns to be openly discussed
by people who feel isolated. In
addition, participation can occur
free of the constraints of time,
distance, and stigma. There re-
mains a need for large clinical
trials to assess the effects of such
Internet-based support groups
(Houston et al., 2002).
Given current interest grow-
ing in the various technologies
(e.g., online discussions, portals,
e-consultations) and increased
consumer knowledge, there is
potential to develop and evalu-
ate various clinical innovations.
Therefore, it is important that
mental health nurses are aware
of not only advances in tech-
nological health care delivery
models and their convenient
features, such as accessibility
(Repique, 2007), but also the
various challenges this technol-
ogy presents.
e-MENTAL HEALTH
CHALLENGES
Notwithstanding e-healths
many positive aspects, the use of
e-health poses several challenges
for both consumers and health
service providers. Challenges to
informed consent, privacy, and
equity (Eysenbach, 2001) may
present legal and professional
hurdles when the Internet is used
for direct behavioral health ser-
vices, such as counseling (Hor-
gan, Merrick, Reif, & Stewart,
2007). The use of many of these
health care technologies has
grown without adequate consid-
eration of the development of an
appropriate infrastructure.
Consumers should under-
stand not only the benets of
e-mail use, but also its risks and
appropriate practices (Car &
Sheikh, 2004). According to
these authors, health care work-
ers are concerned about the
safety, security, and quality of
e-mail consultations, and it has
been suggested that it might be
prudent to standardize specic
communications, such as advis-
ing patients not to use e-mail
for urgent communications, dis-
couraging e-mail consultations
with unknown individuals, and
using automatic replies for unso-
licited e-mails (Car & Sheikh,
2004). Misunderstandings can
be common in Internet com-
munication without the human
aspect of interaction (Scharer,
2005b; Simpson, 2005). Nev-
ertheless, according to Finfgeld
(2000), such deciencies may
neutralize some biases, such as
those related to gender, socio-
economic status, and race.
Some studies have highlighted
the potential disadvantages of the
use of e-mental health. In a lon-
gitudinal study by U.S. research-
ers, the Internet was found to be
mainly used for communication
purposes. However, greater use
was associated with participants
communicating less within their
own households and resulted in
a decline in the size of their so-
cial circle (Kraut et al., 1998). In
addition, greater loneliness and
depression were reported among
heavy users (Kraut et al., 1998).
Some researchers have ex-
pressed concerns that Internet
use is addictive and is associated
with loneliness, depression, so-
cial withdrawal, family discord,
divorce, and job loss (Wieland,
2005). Others suggest there is no
proof of causality and that people
who are lonely and depressed
may seek to alleviate their dis-
tress through online resources. In
addition, the advantages online
support and e-health can bring
to those who need help may out-
weigh the potential of becoming
addicted, if addiction to use, per
se, is possible (Bell, 2007). Ac-
cording to Finfgeld (2000), it is
those individuals with obsessive-
compulsive habits who are vul-
nerable to addiction.
Another possible problem is
that a reliance on e-health may
deepen the gap between the
haves and have-nots, as those
without money, skills, or access
to computers (perhaps those who
might benet the most) are least
likely to benet; this may be more
evident in demographic groups
such as rural and aging popula-
tions (Christensen & Grifths,
2002; Duffy, 2002; Eysenbach,
2001). This is pithily referred to
as the digital divide (Farrell &
McKinnon, 2003, p. 24).
In a randomized, controlled
trial in the rural United States,
researchers testing an online
risk-reduction intervention for
HIV found that low Internet
connection speed reduced the
sophistication of the interven-
tion and perhaps its use (Bowen
et al., 2007). In another study,
young people ages 10 to 16 in the
United Kingdom reported prefer-
ring to access health information
on substance use and abuse via
communication technology and
were comfortable doing this, as
such technology was considered
a part of their life (Chambers,
Connor, & McElhinney, 2005).
However, this may not be the
case for older populations.
There may also be issues re-
garding the possible delay of
necessary face-to-face treatment
while relying on online assistance
for too long and, with an inabil-
ity to communicate nonverbal
signals, some interactions may be
misunderstood (Finfgeld, 2000).
Further disadvantages exist, in-
cluding the ready sharing of in-
accurate information (Simpson,
44 JPNONLINE.COM
2005) or harmful material, such as
that found on pro-anorexic Web
sites (Bell, 2007). It is therefore
important that Internet-based e-
mental health programs are indi-
vidually tailored and monitored
for quality and appropriateness
(Grifths, Bennett, Brittliffe, &
Christensen, 2006).
In an Australian national
study, workshop participants
identied eight main disadvan-
tages regarding the implementa-
tion of e-mental health initia-
tives (Christensen et al., 2002):
l Expensive cost to develop,
including continuing mainte-
nance costs.
l Increased short-term costs,
because previous nonusers begin
to also use conventional and oth-
er health services.
l Issues of ethical responsi-
bility and liability.
l Compromised privacy.
l Nonuniform and possibly
poor information quality.
l Lack of evidence of efcacy.
l Limited access for some
groups.
l Nonuniversal availability
of technology, limiting the ex-
tent to which Internet technolo-
gies can be used.
These are early perceptions and
opinions of e-mental health, and
further international research is
required to more clearly articulate
its merits and ascertain whether
such views can be generalized.
At this stage, some projections
may seem to be contradictory and
may shift over time. Whether,
for example, potential benets,
such as increased access to men-
tal health services, will outweigh
the potential for reduced access
among particular social groups
remains to be seen. Both out-
comes are feasible. As the results
of future studies about the effects
of e-technology use become ap-
parent, new circumstances, ethi-
cal issues, and models of use can
evolve (Simpson, 2005). More
research is needed to fully evalu-
ate the pros and cons of using e-
health across multiple and differ-
ent populations.
Clearly, as indicated above,
technology advances are chang-
ing the way health care provid-
ers deliver services. Although
there are apparent advantages, a
responsibility also exists that the
best interests of the consumer are
served (Scharer, 2005b; Simpson,
2005). To overcome the digital
divide, innovative ways (e.g.,
funding opportunities, adapting
products to meet special needs)
need to be found to enhance ed-
ucation and support, particularly
in isolated locations (Farrell &
McKinnon, 2003).
e-MENTAL HEALTH
RESEARCH
Mental illnesses impose a sig-
nicant burden on the health
and well-being of individuals and
communities worldwide. Five of
the worlds 10 leading causes of
disability are related to mental ill-
ness. The share of global disease
burden associated with mental
illnesses is predicted to increase
in the coming decades (World
Health Organization, 2001). In
addition, approximately 20% of
all individuals will experience
some form of mental illness in
their lifetime.
During the past decade, such
statistics have led many health
professionals to undertake re-
search as a means of improving
the diagnosis and treatment of
the major mental disorders. More
recently, the importance of active
consumer involvement in mental
health research has become a ma-
jor priority (Hanley, Truesdale,
King, Elbourne, & Chalmers,
2001; Trivedi & Wykes, 2002).
E-technology is one medium that
has been found to effectively ad-
dress barriers to consumer par-
ticipation in research (Grifths,
Christensen, Barney, et al.,
2004). For example, one major
threat to research projects that
include mental health consumers
is the illness itself. Traditionally,
if a study participant became un-
well and could not participate in
research on a given day, the proj-
ects protocol was breached, and
the study faced signicant time
delays and increased costs. The
Internet offers such individuals
widespread access to a project 24
hours per day, 7 days per week.
Therefore, unwell participants
can continue to take part in a
given study at a time and place
that most suits them.
However, there are some dis-
senting views about the merits of
Internet research. For example,
Cantrell and Lupinacci (2007)
evaluated an online data col-
lection method and found pro-
longed recruitment and much
missing data and warned that
Web-based research requires
careful consideration.
To date, the role of e-technol-
ogy in mental health research
has not been formally evaluated.
However, previous work about
the Internet and mental health
has examined the use of Internet
communities (Powell, McCarthy,
& Eysenbach, 2003), developed
The use of e-technology presents a range of
benets, but the potential disadvantages should
not be overlooked.
JOURNAL OF PSYCHOSOCIAL NURSING VOL. 46, NO. 4, 2008 45
and evaluated online interven-
tions such as Internet-based
therapy (Andersson et al., 2005;
Christensen, Grifths, & Jorm,
2004; Grifths, Christensen,
Jorm, Evans, & Groves, 2004),
assessed the quality of informa-
tion on mental health Web sites
(Grifths & Christensen, 2000),
and measured the extent to which
the general public and consum-
ers seek mental health informa-
tion using the Internet (Powell
& Clarke, 2006). Robertson et
al. (2006) suggested that future e-
health project evaluations include
large randomized, controlled tri-
als and analyses of outcomes and
costs. They also cautioned against
e-health replacing direct care and
recommended that e-health be
viewed only as an adjunct. For
researchers, Internet programs
provide an opportunity to exam-
ine the effects and outcomes of
health services on large numbers
of people who may not be other-
wise able to obtain help (Grifths
et al., 2007).
Lessons learned from the re-
search described above, together
with the information collated at
the workshops by Christensen et
al. (2002), allowed for the de-
duction of key advantages and
disadvantages of using e-mental
health for research purposes. Key
advantages included:
l Cost effectiveness.
l Large sample sizes.
l Self-paced nature.
l Novel and automated
methods.
l Improved data manage-
ment (direct coding).
l Allowance for sensitive ar-
eas to be better researched, with
better participation rates.
l Immediate and real-time
links to services and information.
Disadvantages included:
l Possibility of biased samples
(i.e., only suitable for competent
Internet users with adequate
equipment).
l Impersonal nature.
l Allowance for self-report
only.
l Possibility of the question-
naires interface affecting responses.
l Inappropriateness of some
topics.
l Unregulated quality assur-
ance (i.e., participants compre-
hension levels).
These areas resonate with nd-
ings from other studies (Ahern,
2005; Duffy, 2002; Mrayyan, 2006)
that identied similar advantages
(e.g., cost effectiveness, large sam-
ple sizes, anonymity, variety of ways
to conduct research) and disadvan-
tages (e.g., biased samples, privacy
issues, undeliverable surveys).
Although e-mental health
research currently seems to have
many disadvantages, it has been
postulated that consumers on-
line participation will only con-
tinue to increase. As noted by
Christensen et al. (2002), such
growth will be largely due to the
development of:
l Consumer-oriented health
care models.
l Cost-containment efforts
that reduce clinicians time with
patients and raise concerns about
best care.
l Emphasis on prevention.
l An aging population with
increased health care needs.
l Increased interest in alter-
native treatments.
The above discussion suggests
that e-technology has a poten-
tial role in future mental health
research. This role will only
continue to increase as more
consumers, caregivers, health
professionals, and other mem-
bers of the general population
go online. With current interest
growing in the various technolo-
gies, there is potential to develop
and evaluate new ways of dis-
seminating health information
and conducting research (Cham-
bers et al., 2005). Given the vast
amount of information on the
Internet already and the con-
tinued proliferation of Web sites
(Christensen & Grifths, 2000),
it is important that mental health
researchers are at the forefront of
this development.
In addition, it must be ac-
knowledged that the population
participating in research on the
Internet may not be representa-
tive (i.e., have higher education
levels, are younger), so research us-
ing these technologies may present
a biased view and neglect minor-
ity groups. The issue of recruiting
participants, which is particularly
relevant with the growth of more
Web sites, must also be addressed.
That said, no large sustainable
models of e-mental health exist;
hence, major challenges for the fu-
1. The Internet is the fastest growing e-technology in the world, and more
research is needed to fully evaluate the pros and cons of using e-health.
2. The role of e-technology, particularly with its ongoing renement, will continue
to increase as more consumers, caregivers, health professionals, and members
of the general population go online.
3. With current interest growing in the various technologies (e.g., Internet, e-mail,
e-consultations, telepsychiatry) and with increased consumer knowledge, a
potential exists to develop and evaluate new ways of conducting research.
Do you agree with this article? Disagree? Have a comment or questions?
Send an e-mail to Karen Stanwood, Executive Editor, at kstanwood@slackinc.com.
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K E Y P O I N T S
46 JPNONLINE.COM
ture include determining who will
pay for e-mental health (Grifths
et al., 2007) and how the ethical
issues will be addressed.
CONCLUSION
As information technology
continues to grow and consumer
use increases, the proliferation
of e-mental health and research
is inevitable. It is obvious that
the use of e-technology presents
a range of benets, but the po-
tential disadvantages should not
be overlooked, particularly the
digital gap between the haves
and have nots. At this stage,
some projections may seem to
be contradictory and will likely
shift over time. Whether, for ex-
ample, potential benets, such as
increased access to mental health
services, will outweigh the po-
tential for reduced access among
particular social groups remains
to be seen. Further international
research is needed to fully evalu-
ate the pros and cons of using e-
health across multiple and differ-
ent populations.
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Dr. Cleary is Clinical Associate Pro-
fessor of Mental Health, Faculty of Nurs-
ing and Midwifery, University of Sydney,
and Clinical Nurse Consultant, Research
Unit, Sydney South West Area Mental
Health Service; Dr. Walter is Profes-
sor of Child and Adolescent Psychiatry,
University of Sydney, and Area Clinical
Director, Child and Adolescent Mental
Health Services, Northern Sydney Cen-
tral Coast Health; and Ms. Matheson is
Research Ofcer, Research Unit, Sydney
South West Area Mental Health Service,
Sydney, New South Wales, Australia.
The authors disclose that they have
no signicant nancial interests in any
product or class of products discussed
directly or indirectly in this activity. The
paper on which this article is based was
supported by an Educational Grant
from Janssen-Cilag.
The authors thank Tracey Davenport
and Georgina Luscombe for their initial
contribution to the development of the
article.
Address correspondence to Michelle
Cleary, RN, BHlthSc(Nurs.), MHlthSc(Nurs.),
PhD, Clinical Nurse Consultant, Research
Unit, Sydney South West Area Mental
Health Service, PO Box 1, Rozelle, New
South Wales, 2039, Australia; e-mail:
michelle.cleary@email.cs.nsw.gov.au.
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