Health consumers are increasingly turning to the web to find health information and to get direct assistance for their health needs. The Pew Internet & American Life Project found that 75% of internet users have searched for health information online.1 More recent polling, in 2008, found that 23% of internet users had searched for information about depression, anxiety, stress or mental health conditions.2 Polling also indicates that consumers living with a disability or chronic disease are more frequent internet users, and more likely to state that they made health decisions based on information found on the web.2
Consumers are also seeking direct help through web-based interventions and therapy services.3 Web interventions offer therapeutic assistance for a range of mental health conditions. Some offer automated self-help on open access websites, while others provide interactive screening, guided assistance through helplines, supervision by a health professional, or a full virtual clinic experience.4-6
A major problem with the proliferation of web intervention sites is that the quality of services provided by or through the website may not be high. Assessing the quality of health information on the internet has long been recognised as a challenge by researchers and policymakers,7 prompting a range of responses including quality labels based on compliance with codes of conduct (such as the Health On the Net Foundation’s HONCode; http://www.hon.ch); rating tools designed for consumer use;8 and automated quality indicators9 and portals that provide “gateways” to high-quality information.10 These quality indicators aim to assist consumers to identify high-quality passive health information. However, consumers also need assistance in identifying high-quality health interventions on the web, as these become more common. One response to this growing need is to provide an accessible list of current web interventions and services, along with information about their availability and evidence-based quality.
Here, we describe the development and features of a web portal named Beacon (http://beacon.anu.edu.au), which provides information about a range of web interventions used in the prevention or treatment of health disorders. This report focuses on Beacon’s health applications for generalised anxiety disorder, social anxiety disorder, panic disorder, post-traumatic stress disorder and depression.
Beacon was designed to list all therapy and prevention sites, as well as health information or psychoeducation sites for which there is evidence of efficacy or effectiveness. Websites are categorised into diagnostic or health categories, and the scientific evidence on which they are based is evaluated. Beacon has the capacity to collect demographic and mental health information from its users, to publish user feedback about the websites it lists and to examine associations between users’ mental health symptoms and web behaviour.
Our search strategy was threefold. In February 2009, we first identified sites for which there was scientific evidence on efficacy or effectiveness, by reviewing all systematic reviews of the efficacy or effectiveness of mental health websites, including a comprehensive book by Marks and colleagues that reviewed the literature available to May 2006.11 We re-ran this book’s literature search terms for the period May 2006 to February 2009 to identify further sites. Details of this search are available on the Beacon website under “FAQ” (frequently asked questions). A website that lists the titles of literature on e-health research (http://construct.haifa.ac.il/~azy/refindx.htm) was also searched to locate relevant websites.
Second, we identified potentially relevant sites and then searched for relevant supporting research literature. In particular, we undertook an internet search of relevant Open Directory Project (ODP; http://www.dmoz.org/about.html) categories corresponding to International Classification of Diseases medical diagnoses (eg, depression, asthma). The ODP is a web directory edited by volunteers and claims to be the largest human-edited directory of the web. All links within these sites were also searched for links to other potentially relevant sites, and additional information was sought from site owners.
Finally, we sought details of web applications from all members of the International Society for Research on Internet Interventions (http://www.isrii.org) through the society’s virtual network.
Searches were conducted by one person in the team (A L C) in February 2009 and sites uploaded to Beacon as ratings of quality were finalised and validated. New searches are conducted 6-monthly, but sites are published immediately and continuously on Beacon as ratings are completed. Data for this report used websites listed on the Beacon website as of March 2010.
To be included in Beacon, sites were required to offer interventions (treatment or prevention) to reduce symptoms or improve health functioning, quality of life or help-seeking capacity. Health conditions included mental disorders (including depression, generalised anxiety disorder, social anxiety disorder, panic disorder), physical illnesses, and sleep and behavioural problems (including eating behaviour, drug and alcohol use, and smoking). Sites were included regardless of whether they were open access or access was contingent on enrolment in a research trial or a health service. Intervention sites were included regardless of whether or not there was evidence for their efficacy or effectiveness. In contrast, as the pool of sites providing mental health information or psychoeducation is large and increasing rapidly, these were only included if there was evidence that they were efficacious.
All identified sites were described in terms of the site structure (eg, website, game), target condition (eg, panic disorder), target age group (eg, adult, child, youth), program content (eg, cognitive behaviour therapy, interpersonal psychotherapy), program length (eg, long — more than five modules), intervention type (eg, automated, supported), support provided (eg, access to trained support workers through a helpline), language, and supporting scientific evidence.
All sites were rated on a 7-point scale from − 1 to 5 (Box 1), accompanied by an explanation for the rating that comprised a brief comment and, in some categories, a link to additional information. Quality ratings were initially made by one researcher (K M) and verified later by another (A L C). Discrepancies in ratings were resolved through discussion between the two raters or with input from a third researcher (H C).
The Beacon website tracks and records the characteristics and behaviour of its visitors. Beacon users register on the site, consent to the collection of data about their symptoms, and complete introductory surveys that capture data on their age, remoteness of residence, education levels, current levels of depression and anxiety, symptoms of panic, levels of disability and social problems. Depression and anxiety are measured using the Goldberg Depression and Anxiety Scales.12 The web behaviour of the visitor is tracked to permit an examination of the relationship between symptom levels and on-site behaviour. Beacon users are sent an email 2 weeks after initial registration, which repeats introductory questions and invites feedback about their experience with the websites listed on Beacon.
The Beacon site has an administrator interface that allows new information to be uploaded, and to track the status of the evaluation of the website. Web users are able to post information about their satisfaction with and experience of each of the websites listed. Website developers of individual sites can provide information about their sites to the Beacon administrator using online forms and can apply directly for inclusion of their sites in the Beacon database. The administrator interface allows the administrator to approve consumer information sent to Beacon, to answer emails, and to liaise with website owners.
By March 2010, 183 websites had been identified for inclusion in Beacon, of which 122 focused on physical health or wellbeing, 40 focused on anxiety and 23 focused on depression. Box 2 lists those mental health websites published on Beacon with ratings of 2 or above.
The 40 sites identified for anxiety disorders all offered interventions rather than information or assessment. Eight offered interventions for generalised anxiety disorder: one achieved a rating of 3, three achieved a rating of 2, and four sites had either no evidence or were under review. Three social anxiety disorder sites were identified: one with a rating of 4, one with a rating of 3, and one with no research evidence. Ten panic disorder sites were identified: one achieved a rating of 4, one a rating of 3 and one a rating of 2. Five post-traumatic stress disorder sites were identified: ratings of 3 and 2 were achieved by the two sites in Box 2. One site achieved a rating of 1 and the two other sites were without evidence. Other sites were identified for test anxiety, public speaking, and claustrophobia (one site for each), obsessive compulsive disorder (three sites) and stress (eight sites). These categories were either too small for further analysis or did not correspond to a psychiatric diagnosis.
Twenty-three depression sites were identified. All were intervention sites except one that provided health information and online assessment (BluePages). One site achieved a rating of 3, three sites achieved a rating of 2, six sites achieved a rating of 1, and 12 sites were without evidence. The remaining depression site was identified through our searches and did have experimental support, but it was no longer available on the internet. A further three sites focused on bipolar disorder and one on suicide ideation.
Beacon provides information on a variety of interventions for anxiety and depression on an open access website that can be reached by the public and health professionals. There is emerging evidence that high-quality psychoeducation can improve the public’s knowledge of effective treatments and some evidence that it can also reduce levels of symptoms.22 Websites can be accessed anonymously, at convenient times, and in rural and remote areas. For clinicians, Beacon provides information on sites that may be useful for their patients or clients, either as self-help tools or as programs for use in low-intensity practitioner-facilitated interventions. High-quality sites may also be of use to community organisations, such as Lifeline, who wish to offer practical help. The Beacon website, through its compilation of new web interventions, identifies gaps in services and may prevent the duplication of multiple website services targeting the same population groups. It also identifies sites that may be of use for citizens of countries with developing economies who have no other access to psychological help.
A number of limitations of the Beacon website need to be acknowledged. Beacon is a portal that aims to improve the quality of information about web interventions. Portals require time, effort and training to maintain, and updating of the database will always involve a time lag. Beacon also involves the review and moderation of consumer input, as users are encouraged to post information about their experiences using the sites. In recognition of the demands of maintaining the site, we have automated many components to reduce the time burden.
Other potential criticisms of Beacon concern the search criteria used to find sites, as these may have excluded some evidence-based materials, and the criteria that are used to measure quality and efficacy or effectiveness. There may also be debate about the rating scale. Sites are rated on the basis of whether research trials indicate they demonstrate positive effects over control conditions (regardless of whether these conditions are wait-list or attention placebo). However, all sites are included regardless of evidence of quality. The source of the rating is clearly indicated in the individual entries, for the information of clinicians and consumers.
Finally, although our aim is to provide a useful service to the community, we do not yet have outcome data to determine whether users of the portal value the service, use it in the way that it is intended to be used, or benefit from exposure to it. Further, we do not know whether the service is used by those for whom it is designed (eg, people with high levels of anxiety and depression symptoms with an unmet need for help). However, Beacon is designed to answer these questions through the capture of online information and user behaviour. Symptom levels of major mental disorders are measured at registration. We are able to examine whether consumers at risk for particular disorders self-navigate to relevant sites, and we follow up all registrants (with their permission) 2 weeks after their first visit to investigate whether their symptom levels have lowered. With sufficient web visitors, we will be able to report the results of these investigations, and begin to estimate the value of the site to the community.
1 Beacon ratings of scientific quality of health websites
2 Quality websites for mental health, based on evaluations from Beacon*
MoodGYM |
When you register for MoodGYM, you are taken through a program of modules that teaches you about your mood and how to change it. The tutorials are completed at your own pace, and through quizzes and exercises you are given feedback about your mood and what your results mean. The site provides information about depression and anxiety, and the role your thoughts play in affecting your emotions. For example, you are taught to identify “warpy thoughts”, develop problem-solving skills, and learn to cope with life events. |
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FearFighter |
The FearFighter program uses self-exposure to address anxiety, panic and phobia. It is a practice-based self-help treatment system that encourages you to identify your specific problems and develop treatment goals. Access to the program is granted through Primary Care Trusts in the United Kingdom, and eligibility for FearFighter is assessed by a support worker. The program comprises nine key steps, which begin with self-rated questionnaires, information about self-exposure therapy, and advice on seeking support for treatment. The remaining six steps involve identifying your own personal triggers to panic and their related problems, constructing homework tasks involving exposure for each trigger, planning for and learning good coping strategies in situations involving panic and the practice of these during self-exposure, reviews of homework tasks with feedback, and planning for the future to maintain progress and prevent relapse. FearFighter provides access to a helpline run by trained support workers, and during the program you receive a number of calls from a support worker assigned to you. It is approved by the UK National Institute of Health and Clinical Excellence. |
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Online Anxiety Prevention Project |
The Online Anxiety Prevention Project aims to prevent the development of serious anxiety disorders in those with anxiety sensitivity (the degree to which you believe symptoms of arousal can negatively impact upon you). A pre-intervention assessment determines whether you can benefit from the program. The intervention contains six modules that include psychoeducation, relaxation training, interoceptive exposure (which focuses on the ability to perceive sensations within the body, such as heartbeat and sweating), cognitive restructuring to change negative thoughts, and relapse prevention. Each module requires participants to work through information and complete exercises designed to teach them the skills to prevent and manage severe anxiety or worry. Practising each skill frequently is highly encouraged, as is recording progress. |
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The BRAVE Program |
BRAVE-Online uses CBT techniques to treat childhood anxiety. There are two available versions: one tailored to children aged between 8 and 12 years and a second for teenagers aged 13 to 17. Each version contains weekly sessions for participants and their parents, which take about 1 hour. BRAVE-Online focuses on developing skills to manage anxiety, such as the recognition of its physiological signs, relaxation strategies, cognitive training including self-talk and restructuring, exposure, problem solving, and empowerment. The parent sessions aim to help parents better assist their children manage their anxiety through psychoeducation and instruction on management techniques. Automated feedback is provided following exercises, and each family is assigned a therapist who provides feedback by email each week and calls the family in the middle of the program to assist with their exposure strategies. |
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Shyness Program |
The Shyness Program is divided into four sections: CBT modules, homework assignments, an online forum, and email contact with a clinical psychologist or psychiatrist. The CBT modules present the story of a young man who suffers from social phobia. As you move through the program, you follow him as he develops the skills to overcome his fears. The six CBT sessions build on one another and focus on psychoeducation, the development of exposure strategies, changing negative thoughts, and information about preventing a relapse. Homework assignments are expected to be completed for each module and you are also asked to participate in an online forum designed to promote support and learning. You have access to a therapist by email if you need help. |
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InternetPsykiatri program for social phobia |
The InternetPsykiatri program for social phobia primarily comprises an online manual, which is read by the participant over 15 weeks. The program content focuses on psychoeducation for social phobia and its symptoms, as well as the relationship between thoughts, feelings and behaviour in the disorder. It provides skills training in identifying automatic thoughts and cognitive errors, and challenging these to reduce their impact on anxiety. In addition, the InternetPsykiatri program for social phobia includes interactive quizzes to monitor symptoms, and also offers assistance from professionals by email. |
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Panic Online Step 2
http://www.swinburne.edu. |
Panic Online Step 2 follows the initial Panic Online Step 1 program (see below) and is based on CBT. It is designed to help you understand and master strategies effective in reducing the impact of panic disorder in your life. The program structure includes an introductory module, four learning modules, and a concluding module focusing on relapse prevention. It utilises treatment methods and principles of CBT, such as controlled breathing, changing your thinking, and exposure to stimuli or events. The program includes interactions by email with therapists, who assist with questions about the program and provide support and feedback on your progress. There are also additional features focusing on relaxation training and exposure techniques. |
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FearFighter
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Panic Online Step 1 |
The Panic Online Step 1 program contains five modules that are aimed at helping you understand panic disorder. The modules provide information on the nature of panic, its causes and impact; the cognitive, physiological and behavioural components of panic and how they influence one another to affect you; instruction on negative and self-defeating thoughts and how to change these; and different strategies for coping with panic attacks. The program does not provide instruction on exposure strategies. After completion of each module, there are quizzes that test your comprehension of the material and provide you with feedback on correct responses. |
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Interapy |
Interapy uses CBT to address post-traumatic stress through habituation and cognitive reappraisal. The program is accessible only if an initial assessment suggests you can benefit from it. If eligible, Interapy involves 10 writing sessions over 5 weeks, each taking about 45 minutes. These correspond to three treatment phases in which therapists give you feedback and instructions. Phase 1 focuses on self-confrontation and provides psychoeducation about exposure therapy. In Phase 2, you receive psychoeducation about cognitive reappraisal and write encouraging advice to a hypothetical friend who experienced the traumatic event. This task helps you take a new perspective on the event, particularly its positive effect on your life and the lessons learned. Phase 3 involves two sessions in which you share your experience and farewell your trauma by writing a letter to a friend or yourself. |
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Self-Help for Traumatic Consequences |
The Self-Help for Traumatic Consequences program uses CBT principles of exposure to reduce and overcome trauma. The program involves the completion of written exercises that describe the targeted trauma and your emotional response. These are then read aloud repeatedly to allow you to accept and move past them. Interactive practice exercises help you develop skills and mastery in each treatment module. Your performance on these tests is assessed and you receive feedback on your performance. |
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MoodGYM |
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BluePages |
BluePages is a comprehensive site about depression. It offers quizzes for depression and anxiety, and also information about the symptoms and prevalence of depression, and general and specific sources of help. BluePages provides evaluations of medical, psychological, and alternative/lifestyle approaches to treatment. The site also includes BlueBoard, a forum through which you can talk to other people who have experienced or are interested in learning about depression. |
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InternetPsykiatri program for depression |
This cognitive behavioural self-help program offered by InternetPsykiatri is a 10-module program completed over 10–12 weeks. The depression program focuses on learning about depression and developing CBT skills. It provides training in behavioural activation (to improve engagement with positive activities in the environment) and cognitive restructuring to change dysfunctional thought processes that have a negative impact on emotions. The program also provides help to improve sleep and overcome difficulties related to it, and has a strong focus on relapse prevention. An individual’s symptoms of depression are tracked throughout the program, and there is some access to psychiatrists for assistance with the program. |
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Kleur je leven |
The Kleur je leven program is a self-help intervention comprising eight modules about depression. You can read information about depression, complete exercises, and learn from videos and figures. It is based on CBT, which means you learn about how to manage and prevent depression by changing the way you think and behave. The program includes instruction on communication, assertiveness, stress, problem solving and planning. |
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CBT = cognitive behaviour therapy. * Sites with a rating of 2 or more (see Box 1). † Based on the description provided on Beacon. |
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- Helen Christensen1
- Kristen Murray2
- Alison L Calear3
- Kylie Bennett4
- Anthony Bennett5
- Kathleen M Griffiths6
- Centre for Mental Health Research, Australian National University, Canberra, ACT.
We acknowledge the assistance of Alex Aiken in extending the Beacon database. Helen Christensen is supported by National Health and Medical Research Council (NHMRC) Fellowship 525411 and Kathleen Griffiths by NHMRC Fellowship 525413.
Helen Christensen and Kathleen Griffiths developed MoodGYM and BluePages, which are listed on Beacon. Helen Christensen has received occasional honoraria from Eli Lilly for general practitioner educational workshops.
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- 18. Klein B, Richards JC. A brief Internet-based treatment for panic disorder. Behav Cogn Psychother 2001; 29: 113-117.
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- 22. Donker T, Griffiths KM, Cuijpers P, Christensen H. Psychoeducation for depression, anxiety and psychological distress: a meta-analysis. BMC Med 2009; 7: 79.
Abstract
Objective: To describe the Beacon web portal, which lists and rates quality health websites, collects user characteristics and publishes user feedback; and to report summary data on Beacon’s highest-rated (best evidence-based) sites for mental health.
Data sources: A systematic search was undertaken in February 2009 for potentially relevant websites through a review of research papers and a recently published book, an internet search of Open Directory Project medical categories, a review of material on a high-profile mental health portal, and a survey of international researchers.
Selection criteria: All sites were ranked on a 7-point scale from − 1 to 5, with negative scores indicating evidence of no effect and scores of 2 or more indicating evidence of efficacy based on reports in the scientific literature.
Results: By March 2010, 183 sites had been identified, of which 122 focused on physical health or wellbeing, 40 targeted anxiety, and 23 targeted depression. Of the eight generalised anxiety disorder sites identified, four achieved ratings of 2 or above. Two social anxiety disorder sites achieved scores higher than 2. Ten panic disorder sites were identified, with three achieving ratings of 2 or above; and five post-traumatic stress disorder sites were identified, with two achieving ratings of 2 or above. Of the 23 identified depression sites, four achieved a rating of 2 or above.
Conclusions: There are a number of high-quality mental health websites on the internet, and Beacon provides a portal to enable the wide dissemination of these resources.