Use of the Internet and Other Media for Health Information Among Clinic Outpatients With Serious Mental Illness

In a cross-sectional study, we recruited patients with serious mental illness from two outpatient mental health treatment centers and one assertive community treatment site. All sites are affiliated with a university hospital located in an urban city in the mid-Atlantic region of the United States. To maximize external validity, inclusion criteria were intentionally broad; they included being an adult (age 18 and older), attending one of the three mental health clinics noted, and being able to speak and read English.

The research project was approved by the University of Maryland, Baltimore, Institutional Review Board and the Johns Hopkins Bloomberg School of Public Health Committee on Human Research. A total of 140 potential participants were approached from February to December 2007. Five were deemed ineligible on account of their inability to read English. Thirty-five refused to participate in the study. The most common reason for refusal was lack of interest in participating in the study. A total of 100 participants provided informed consent and completed the study. Participants were paid $5 to compensate them for their time and effort.

A media use survey instrument, previously used with adolescent samples, was modified and updated for this research ( 12 ). The instrument included 119 items. These items evaluated several domains, including demographic characteristics, medical and mental illness history, ownership and use of technology, and perception and behaviors regarding health information. The instrument also included specific questions about current mental health Web sites.

The definition of serious mental illness was based on participants' responses to the following question: "Have you ever been told by a doctor or other mental health professional that you had: (1) schizophrenia, (2) manic depression, also called bipolar disorder, (3) major depression (includes dysthymia) or (4) anxiety disorder (includes panic disorder, phobias, obsessive-compulsive disorder) or (5) any other mental or emotional disorder?" A hierarchical algorithm was used to ensure that these diagnoses were mutually exclusive.

Univariate distributions included percentages for dichotomous variables and means for normally distributed continuous variables. We used two-sided t tests to compare means and chi square tests to compare percentages. Data were analyzed with SPSS (version 16.0). All reported p values are two-sided.

Two-thirds (N=63) of the sample was male, nearly three quarters (N=72) was African American, and 79% were age 40 or older. Over a third (N=36) had less than a high school education, and 83% reported earning less than $10,000 per year. Forty-three percent lived independently (in a private home, apartment, or boarding house), and another 29% lived with a roommate or family member in a private home. Twenty-seven percent lived in a residence with at least some assistance or supervision. No participant reported being homeless.

The most common mental disorder for which participants were receiving treatment was schizophrenia (72%, followed by bipolar disorder (16%), depression (8%), and anxiety (2%). Close to half (45%) received treatment not only for a mental health condition but also for a substance use disorder.

In their current living situation, practically all participants (91%) had at least one television set. Participants watched a mean±SD of 5.7±4.6 hours of television per day. Nearly all participants (87%) had an AM-FM radio. Less than half of the participants reported owning a video player (49%) or having cable or satellite television (44%) ( Table 1 ).

Twenty-eight percent of the participants reported owning their own computer. A slightly higher percentage of participants (34%) reported having access to the Internet.

Thirty-six percent reported ever having used the Internet. Among the Internet users, slightly over a third (36%, N=13) used the Internet just a few times a year. Another 30% (N=11) reported that they used the Internet a few days a month, and 33% (N=12) said they went online several times a week. The most common access location was the library (reported by 72% of Internet users, N=26), followed by a family member's home (36%, N=13), one's home (31%, N=11), and a local community center (22%, N=8).

Neither gender nor ethnicity was associated with Internet use; however, age and education level were related to reported use. Younger participants were significantly more likely to report having used the Internet ( χ ² =14.6, df=2, p<.001). Seventy-one percent (N=15) of participants under age 40 had used the Internet, compared with 28% (N=13) of 40- to 50-year-olds and 24% (N=8) of those older than 50. For those without a high school degree, just 14% (N=5) had used the Internet. Forty-three percent (N=21) of high school graduates and 67% (N=10) of those with some college experience had used the Internet ( χ ² =14.8, df=2, p<.001). Reported annual income, which varied little in this sample, was not significantly associated with Internet use.

Reported barriers, indicated by more than half of the 64 Internet nonusers, included expense (81%, N=52), lack of skills or knowledge (78%, N=50), cognitive difficulties (56%, N=36), problems with typing (55%, N=35), and lack of access to a computer or to the Internet (53%, N=34). Compared with users, Internet nonusers were significantly more likely to report that the Internet was too expensive ( χ ² =9.07, df=1, p=.003) and that they lacked important computer skills or knowledge ( χ ² =9.07, df=1, p<.001), had problems with typing ( χ ² =6.7, df=2, p=.009) or reading ( χ ² =8.3, df=2, p=.004), feared using technology ( χ ² =5.2, df=2, p=.02), and lacked access ( χ ² =13.2, df=2, p=.004).

Although nonusers reported interest in the Internet, only 17% (N=6) described a likelihood of using this technology in the near future. Previous users had significantly higher interest levels and intentions to continue their use.

Participants indicated that they obtained health information from a variety of media. Television was the most popular source, with 74% reporting that they sometimes or often received pertinent information from this medium.

A little more than half (53%, N=19) of Internet users reported that they had gone online for health information. Those who had done this offered that Internet health information was easy to read and understand. Other popular reasons were that the information was useful and that the Internet was fun to use.

Of those who used the Internet to look up health information, 80% (N=14) had looked up information about mental health-related treatment, diagnoses, and medication. Around half (N=8) had read about a treatment facility and read others' Weblogs (blogs) on mental illness. Less than 20% (N=3) had either read message boards or chatted online with other people who have mental illness or with health professionals. None had contributed to a Web site on mental health, created their own blog, or bought medications online. Finally, although more than half of the Internet users who had gone online for health information (53%, N=9) also reported that they had an e-mail account, just one individual had communicated by e-mail with his doctor or health practitioner.

In this sample of people with serious mental illness, we found that television was the most popular resource for health information. Nearly three quarters of the study participants reported that they sometimes or often received pertinent health information via television. In general, television was readily available, and this group used it, on average, even more frequently that the general U.S. adult population, who watch on average four hours of regular broadcast television per day ( 13 ).

In contrast, only one-third of the participants in this study reported having used the Internet, and among those with Internet experience, usage was reported to be infrequent. This lack of use is consistent with what is observed among other disadvantaged and disenfranchised groups in the United States. For example, in a study of homeless and indigent drug users in California, only 25% had ever owned a computer and just 19% had accessed the Internet in the previous 30 days ( 13 ). Consistent with other research, we found that individuals with serious mental illness who lacked much formal education and who were older were significantly less likely to use the Internet. Recently, the Pew Internet and American Life Project reported that only 38% of people without a high school diploma have used the Internet ( 14 ), and the Kaiser Family Foundation reported in 2005 that 37% of those aged 65 and older had used the Internet ( 15 ).

Just a small percentage of this study's Internet users had ever gone online to find pertinent health information. This is in stark contrast to behavior patterns of other groups, in which seeking health information online is common. A study of persons living with a chronic illness found that about half (51%) went online regularly, and the majority of these individuals (86%) were avid consumers of online health information ( 12 ). Despite infrequency of use of online health information, this study's overall sample reported high levels of interest and trust in using the Internet. Most nonusers and users were willing to follow up on a health provider's recommendation to visit a mental health Web site. Primary barriers for use include expense, lack of technological knowledge, and lack of access to the technology. Only a small percentage lacked interest in using the Internet; most indicated that if barriers were removed through financial support and training, they too would use the Internet to access information and to find care and support online. In addition, future attention may need to be directed toward creating Internet access points and interfaces that reach out to those who have cognitive problems such as trouble with reading or attention issues.

There are limitations to this study. First, our data were based on self-reports of recruited participants. As such, the results may be at risk of either underreporting or overreporting the use of media. Second, the study was conducted in an urban U.S. location and may not be generalizable to other locales. Third, because this study excluded participants who could not speak English, findings might be different among non-English speakers.

Despite low rates of reported Internet access and usage among individuals with serious mental illness, there appears to be interest and willingness in this population to use media, including the Internet, for health information and support. Surmountable challenges, such as cost of Internet access and training (which other disadvantaged members of society also face), need to be overcome if health information and future interventions are to reach people with serious mental illness.

This project was supported by grant K23DA19820 from the National Institute on Drug Abuse. The views expressed in this brief report are those of the authors. No official endorsement by the Department of Health and Human Services or the National Institutes of Health is intended or should be inferred.

The authors report no competing interests.

Dr. Borzekowski is on the faculty of the Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205 (email: [email protected]). The other authors are with the Department of Psychiatry, University of Maryland School of Medicine, Baltimore.