The goals of this study were to determine whether people’s use of the Internet to obtain health resources would have consequences for their psychological well-being and physical health, and whether these consequences were comparable to consequences of other uses of the Internet. We examined whether the impact of using the Internet to obtain health resources might be moderated by participants’ initial health or caregiver status. We found that using the Internet to obtain health information was associated with increased depression over approximately 6 to 8 months, while using it to communicate with friends and family was associated with decreased depression. Interestingly, these associations did not depend on the initial health status of the participants (eg, the presence of serious illness) or whether they were the primary caregiver for an ill person. Furthermore, these uses of the Internet were not associated with changes in individuals’ ratings of their general health.
We did not expect that using the Internet for health purposes would be associated with increases in depression. There are, however, several plausible explanations for this finding. First, the Internet has both good and poor quality medical advice [70
] that is difficult to for an untrained observer to distinguish [10
]. For example, a previous study revealed that only 20% of websites provided correct information on how to take a child’s temperature [71
]. Furthermore, only one third of users verify Internet information with their doctor to ensure accuracy [72
]. It may be that one source of the increase in depression is the misinformation people get from factually incorrect websites. This may lead to inaccurate self-diagnosis, poor health behaviors (eg, herbal remedies), or potentially unnecessary worry (for both healthy and ill populations). This negative rumination could occur when researching one’s own medical problems or those of loved ones, easily leading to depressive symptoms at a later point in time.
Another possible source of depression may come about when people use online health support groups. While health support groups moderated by doctors, nurses, or trained moderators may be an important source of health information, many online support groups do not have professional moderation, and most are composed of strangers. Both the information and the empathy and other types of emotional support people receive from strangers they meet in online support groups may be less valuable than the resources they could get from offline interactions with family and friends. The advice offered in support groups often consists of personal anecdotes that may not be as helpful as medically relevant information [73
]. Moreover, too much time spent in online support groups may displace in-person support and as a result harm the psychological well-being people derive from interaction with friends and family offline [74
]. Results from the current study showing that communicating online was associated with declines in depression when the communication was with friends and family but not with new people; and results from prior research [43
] showing that communication with strangers online may lead to increased depression suggest that discussion of health problems with strangers online may be problematic.
An alternative interpretation is that people who choose to seek out Internet health resources may be especially sensitive to hypochondriasis or excessive worry about minor health symptoms or perceived health risks. The association between baseline depression and seeking health information online is evidence of this. Internet websites and support groups might be compelling for such persons, as they are rife with lists of symptoms, narratives of pain and grief, dire warnings about treatment side effects, and even graphic photos of diseased organs. Reading about symptoms and anecdotes from patients may cause this group to imagine being ill and to inflate their perceptions of risk. Information and discussions of health problems also may cause them to ruminate [28
] and increase their anxiety [27
]. Consistent with this argument is evidence suggesting that those with psychosomatic illnesses are particularly likely to use Internet health resources [23
], and that people with high levels of health anxiety or hypochondriasis use health resources significantly more than their nonanxious counterparts.
The finding that online communication with friends and family reduced the frequency of depression symptoms is consistent with a large literature on social support [76
] and warrants little further discussion. If online communication with friends and family increases perceived social support, this could lead to lower depression and improved psychological well-being. Similarly, maintaining contact with friends and family may enhance the quality of relationships, decrease loneliness and social isolation, and improve the nature of the social network, all of which have been tied to lower depression and improved psychological well-being [78
Although one might be concerned about regression toward the mean, this statistical artifact cannot account for results showing that use of the Internet for health information was associated with increases in depression, but use for communication with friends and family was associated with decreases. Indeed regression artifacts would have produced a pattern of results opposite to the ones reported here. Regression toward the mean occurs because of measurement error, when error causes extreme scores at one measurement period to be less extreme at a different period (eg, people who reported many symptoms of depression at the first survey should report fewer at subsequent periods). Models 1A and 1F in and 2 show that people who were initially more depressed were more likely to use the Internet for health purposes and less likely to use it to communicate with friends and family. If their initial depression caused this pattern of Internet use, then regression toward the mean would cause those people who were initially severely depressed (and therefore selected to use the Internet for health purposes) to appear less depressed at the later period.
The absence of significant effects of the Internet on changes in participants’ general health may stem from insensitivity of the health measure. First, we used a single-item measure of general health, which limits our assessment to perceptions of general health as opposed to any one specific symptom. It is also possible that there is no link between physical health and Internet health resource use, or that it is weakened by other behaviors. For example, if using the Internet for health purposes resulted in appropriate treatment seeking, this might mask a possible connection. Unfortunately, since we do not have data on actions taken or health center visits, we cannot determine if this was the case. Thus far, however, the literature does not show such effects, at least not for unevaluated health resources and unsupervised use [82
]. Most previous studies of online health resources have measured attitudes rather than behavior change. The few studies examining behavior change [83
] have been clinical trials involving physician-supervised, closed Internet sites or moderated support groups rather than free access to Internet resources.
The longitudinal data and analyses reported here allow stronger causal claims about the relationship between Internet use and depression than do cross-sectional data. Because the same individuals were measured at multiple time points, stable characteristics such as demographic differences and personality are automatically controlled when assessing changes in depression. In addition, the lagged dependent variable analysis controls for initial levels of depression and health when predicting subsequent levels of depression and health. Despite the benefits of longitudinal analyses, however, we cannot establish causality solely based on them. In particular, longitudinal analyses do not control for unmeasured variables, such as hypochondriasis, stress, or health behaviors that may also change over time and predict both changes in depression and changes in use of the Internet for health resources. Clinical trials with random assignment are needed to make stronger causal claims.
Our ability to generalize to the US population is limited because we over-sampled Internet users and because only 35% of those initially contacted by telephone completed an outcome measure at least two times. Finally, our data were collected during 2000 to 2002, and the Internet and access to it have changed dramatically since then. The quality of health information and support online may have improved, and Internet users today may no longer use Internet resources in the same fashion as they did during the time period of our study, suggesting the need for follow-up research in this area.
This study examined the consequences of using Internet health-related resources in a way that other studies have not. We used a national sample including both healthy and ill people, and administered a longitudinal survey to discover if using the Internet to obtain health information or interpersonal communication with friends and family predicted subsequent changes in participants’ reported depression and general health. Our results suggest that using the Internet to obtain health resources is associated with increases in symptoms of depression. This finding cannot be interpreted as a broad effect of being online, since we also showed that communicating online with friends and family was associated with declines in symptoms of depression. However, since we did not control the uses of the Internet chosen by respondents, we cannot determine whether these effects were due to characteristics of the individuals or the nature of the online resources they used, or both. Additional research is needed to determine what leads individuals to seek out health resources online, whether the information that they discover (and believe) is factually correct, and what actions ensue.