If I asked you how many adolescents in the UK suffered from a mental illness, what would you do? Reach for your smartphone or laptop and search online? With 91% of 16-24 year olds able to access the Internet, answers to these questions can be found easily. The Internet could be used to simply find out how to work out percentages, or for more serious issues such as mental health

The answer to my original question, by the way, is around 850,000 young people in the UK have a mental illness (see the YoungMinds website for further information).

This trend of online use by adolescents has been recognised and many charities, researchers, and clinicians have tried to connect to their target audience by providing online mental health services. Although 43% of users are searching for health information online, we know very little about how this affects health outcomes.

Not receiving help for a mental health issue at a young age could affect educational attainment and chances later in adult life. It is therefore a high priority that we are targeting this age group in the most effective way. Although many people talk about online services as the first step to further support, an important question to ask is do they actually encourage adolescents to seek further help?

Kauer, Mangan, and Sanci addressed this question and conducted a systematic review that aimed to:

Investigate the effectiveness of current online mental health services in facilitating the help seeking process in young people.

Methods

In line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines the reviewers searched PschINFO, PubMed, and the Cochrane Library for peer reviewed studies, including qualitative studies, with search terms related to the three themes:

1. Web-Based Technology
2. Mental Health
3. Help Seeking

The first author selected studies based on the following criteria, whilst the second author confirmed that the selected studies were suitable for inclusion.

Inclusion criteria

• 75% of the included participants had to be between 14-25 years old
• The main outcome variable was related specifically to mental health and not just health in general
• The online component should be related to mental health
• The online program should be described and evaluated in relation to help-seeking, attitudes or intentions
• The paper should be an empirical study and not a review
• The participants included in the study should be young people, rather than a third party (parent/teacher) seeking help on behalf of a young person

The authors set out to evaluate a very general question, with no formal definition of the search terms, such as help seeking. Mental health is a large field and it may have helped to define these terms to focus and constrain the review, providing clearer outcomes.

The purpose of including both qualitative and quantitative articles was to increase the scope of the review. Although this increased the breadth of information gathered, the mix of studies seemed to dilute the overall message, and made the review harder to follow.

Results

A total of 608 studies were identified through the initial searched (121 of this were identified through manual reference checking). Four hundred and five of these were excluded based on abstract examination, and a further 149 excluded after full text review. This resulted in 18 studies for full review (2 qualitative, 12 cross-sectional, 1 quasi-experimental, and 3 randomised controlled trials (RCTs)).

The mean sample size of the included studies was 762, and the mean number of included females was 67%. The majority of included participants were students and the mean age of included participants in each study ranged from 16.5 – 26.2 years.

Help seeking

• Two RCTs found no evidence to support the hypothesis that young people who received a mental health based internet information intervention would be more likely to seek professional health care
• However, a cross sectional study showed that 75.4% of students indicated that participating in an online mental health-screening tool had enhanced their decision to see a professional
• A further cross sectional study found that only a minority (35.2%) of young people who engaged in an online mental health service thought that the service helped them ask for professional help

Characteristics of young people who sought help online

• One cross sectional study found no link between personality characteristics and online help seeking
• Results from another cross sectional study showed that young people at risk were using online services in combination with other services, rather than substituting one for the other
• A further cross sectional study demonstrated that 30.8% of young people had used the internet to search for mental health information, 68% said they would use the internet if they needed to, and 79.4% said they would prefer face-to-face support
• Additionally most young adults reported using Google to find online help and were unaware of other websites
• Another cross sectional study showed that 78% of those who used online forums were woman, 75% found it easier to talk online compared to face-to-face, and 62% used online services alongside other mental health services
• Variables associated with increased online help seeking in a cross-sectional study included:
  • Previous phone helpline usage
  • Not seeking face-to-face help
  • A suppressive problem-solving approach

Mental health

• A qualitative study found that students reported positive changes and experiences from an online self help program at their university
• In an RCT young adults with depressive symptoms when receiving an online program, compared to those in treatment as usual showed a significant (but modest) reduction in symptoms
• A quasi experimental study found slight but significant improvements in problem solving and seeking help as a result of an online game designed to help those with mental health problems

Facilitators to online help seeking

• Young people were reported to want an Internet program that is useful, credible, private, convenient, and accessible. Awareness of the program and motivation to use it were also consider important factors (found by 1 qualitative, and 2 cross sectional sectional studies).
  • The lack of these points were reported to prevent online help seeking
• Interactive components were valued higher by younger vs. older participants
• Overall experiences of online mental health services were evaluated positively. Nine studies (1 RCT, 1 quasi experimental study, and 7 cross sectional studies) looked at this and found that:
  • 90% of participants were satisfied with the service
  • 86% would use it again
  • 72% would recommend it to a friend
  • 65% found the programs helpful
  • However, only 50% of participants found what they were looking for

Conclusions

The authors reported:

This systematic review highlights the need for rigorous methods of online help-seeking programs… High quality randomised control trials are needed before the implementation of new services as well as ongoing longitudinal trials to ensure the efficacy of existing services…This is not to say that there is no benefit in online services, rather, that this field has yet to be properly evaluated.

Although the research shows that users experiences of online mental health services was positive, there is little evidence to suggest that the online mental health resources assessed, increased help seeking in young people. The lack of change in help seeking in the included studies could be due to methodological issues.

Strengths and limitations

• The review was pre-registered on the PROSPERO website which maximises the transparency of the methods used and minimises possible bias in reporting
• Although inter-rater reliability between the first and second reviewer was checked at a later stage, the initial abstract search was screened by only one person, which could have biased the initial selection of studies
• Both uncontrolled and controlled studies were included in order to provide a breadth of information about the topic, however this meant that statistical methods for determining effect sizes and possible publication bias were not possible
• Only four studies included help-seeking as the primary aim. Heterogeneous outcomes and unvalidated measures limited any direct comparison between studies
• Included studies had small sample sizes, limiting the power to detect possible differences between outcome variables
• There were no longitudinal studies looking at a longer follow-up and whether online services increased help-seeking in the long term

Commentary

This review focused on a large area of research and did not formally define the search terms, which would have been helpful. The concept of online help seeking is hard to define and measure. A formal definition and measurement that is used when evaluating evidence should be developed and implemented universally, so that studies can be statistically compared.

The current evaluation of services is too slow and may not be able to keep up with the rapidly developing online services. The way in which adolescents are currently using online services could be studied and successful features combined to develop a new intervention, evaluated in a longitudinal manner. Enabling a variety of service users from different cultures to become involved in this process would hopefully improve outcomes.

The Internet has provided a forum for individuals to become more informed about their treatment and symptoms, and it is clear that the way in which people seek information is changing. We need to keep up with this change and develop appropriate evidence-based online interventions to meet this need.

As 75% of young people who experience a mental health problem don’t access treatment, online services that alleviate barriers to treatment could be a partial solution to increasing help seeking. Whether or not these interventions will actually improve mental health outcomes, or future help seeking is yet to be known.

Links

Kauer SD, Mangan C, Sanci L. Do online mental health services improve help-seeking for young people? A systematic review. Journal of Medical Internet Research 2014; 16(3): e66

Young Minds website. Last accessed 20 Oct 2014.

PROSPERO database website. Last accessed 20 Oct 2014.

Cotton R et al. The future’s digital: mental health and technology (PDF). NHS Confederation Mental Health Network, 25 Sep 2014.