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Winter 2009/10 | Vol 13 No 2

Focus

Dr. Google

Online self-assessment offers opportunity to link to treatment

By Avril Roberts

Search Google for “depression test” or “alcoholism test” and you’ll get 23.1 million and 9.4 million results, respectively. Clearly, self-assessment is alive and well on the Internet, that modern-day source of second opinions, sometimes even the “doctor” of choice. But whimsical Facebook quizzes aside, many evidence-based mental health and addiction screeners are appearing online, potentially reaching more people than actually seek mental health and addiction services. Online self-assessment tools not only educate; they also offer unprecedented opportunities to help people access care.

Screeners such as the Free Anxiety Screening Test and Check Your Drinking Survey make it easy for people to self-diagnose their mental health or substance use problems in the privacy of their homes, day or night, bypassing many of the usual barriers to seeking help in-person – stigma, embarrassment, location, anxiety and lack of awareness of the degree of the problem.

The anonymity of the Internet also allows people to be more candid about the extent of their substance use or mental health issues and possibly more receptive to information from a perceived non-judgmental source. “It fits with where society is going in terms of how people obtain information about anything, in this case, health information,” says Dr. Michael Van Ameringen, co-director of the Anxiety Disorders Clinic at McMaster University Medical Centre in Hamilton, Ontario.

In a survey of 200 visitors who completed the Free Anxiety Screening Test posted on the home page of McMaster University’s Anxiety Disorders Clinic (www.macanxiety.com), Van Ameringen found that 70 per cent were women, the mean age was 32, and 91 per cent had at least a high school education. Sixty-one per cent said they were concerned that they had an anxiety problem and 17 per cent were trying to confirm a diagnosis. However, 15 per cent said they were testing themselves because they don’t have a family doctor and another 14 per cent said they don’t feel comfortable discussing anxiety with their doctor. “We didn’t expect that at all,” says Van Ameringen. “If you can’t talk to your doctor or don’t have one, that’s a big issue for mental health professionals to deal with.”

More than 90 per cent of the respondents met DSM-IV criteria for an anxiety or mood disorder, most frequently social phobia, major depression and generalized anxiety disorder. Following the self-assessment, 58 per cent planned to seek further assessment from a health professional, and 31 per cent were going to look for more information online.

“You can see that people are using this kind of test to get ready for treatment or to find out more about their condition,” says Van Ameringen. “There’s probably a lot of fear about getting mental health treatment, so online self-assessment could be useful for moving people in the direction of treatment.”

Van Ameringen has seen people arrive at his clinic with printouts of online screeners, particularly for adult attention-deficit/hyperactivity disorder and social phobia. Noting that even if people assess themselves, they may not be able to get treatment immediately, Van Ameringen sees a role for more psychoeducation online. His clinic’s web site links to specialized anxiety treatment services in Canada, among other resources.

Research also shows that web-based screening tools for addiction can be effective, not only educating people about substance use, but also motivating them to change. A recently published randomized controlled trial of the Check Your Drinking (CYD) survey (www.alcoholhelpcenter.net or www.checkyourdrinking.net), looking at drinking outcomes, found that problem drinkers who were directed to CYD had about a 30 per cent reduction in weekly alcohol consumption at three-month and six-month follow-ups, compared to a one drink a week reduction among the control group, which received a written description of CYD and was asked whether they thought its components would be useful.

The research, published in the December 2009 issue of Addiction, involved Ontario adults age 19 and older who were not treatment-seekers; they were already participating in a general population telephone survey and met criteria for risky alcohol consumption. Similar results were achieved in an Australian study, published in 2009 in the Archives of Internal Medicine, where university students completed a web-based version of the Alcohol Use Disorders Identification Test.

CYD asks 18 questions about the person’s drinking habits, provides personalized feedback on the person’s alcohol use and offers normative feedback comparing the participant’s drinking to that of people of the same age, gender and country of origin (Canada, U.S. and U.K., primarily.) It was developed for Evolution Health Systems Inc. by Dr. John Cunningham, Canada Research Chair in Brief Interventions in Addictive Behaviours at the University of Toronto and a senior scientist at the Centre for Addiction and Mental Health.

Cunningham theorizes this type of intervention works because “humans are social animals. They don’t want to think of themselves as being abnormal or weird, so providing information that yes, you’re drinking more than 95 per cent of other males your age can be a surprise,” he says. “But if it’s presented in a non-judgmental way, it can get people thinking about their drinking and motivate them to reduce a bit.”

Cunningham also consulted on the Check Where I'm at with Weed quiz posted on www.whatswithweed.ca, which takes a harm reduction approach to getting youth to assess their cannabis use. He notes that these online screeners attract people who don’t necessarily seek out or may not even want formal treatment – problem drinkers, as opposed to people who are severely alcohol dependent, women, older people and youth. He sees screeners as offering “one good option in a palette of different things people could try.”

A Quebec study led by Dr. Michel Perreault, a researcher at the Douglas Mental Health University Institute in Montreal, and associate professor in the Department of Psychiatry at McGill University, further illustrates the Internet’s reach. The study, published last year in the International Journal of Victimology, used an online questionnaire to explore obstacles to care for anxiety disorders. More than 700 people completed the quiz – 653 had an anxiety disorder and 61 were family caregivers. Forty-three per cent arrived via support group web sites.

The high response rate and the fact that people persevered through a multi-part questionnaire, even when given opportunities to exit, suggested to Perreault that even in hard-to-reach populations, “people are highly motivated to learn more about themselves and their conditions and the services available to them.” The three main treatment barriers that people identified were symptoms; not knowing where to go for a diagnosis, treatment or other services; and issues of access, particularly a lack of funds or insurance coverage for a psychologist.

Recognizing that the Internet is often the first place people look for information, the CYD study concludes: “The Internet could increase the range of help-seeking options available because it takes treatment to the problem drinker rather than making the problem drinker come to treatment.” It’s a statement that may apply to mental health and addiction services in general.