From the Editor

A few years ago, a patient told me that he had won the lottery. When I expressed some surprise (and skepticism), he replied: google my name. I did, and he had won the lottery.

We google restaurant suggestions, people in the news, and our partner’s new bff.  But is googling your patients ethical? Is it advisable?

In the first selection, we look at a new paper from Psychiatric Services. Yale University’s Charles C. Dike and his co-authors consider these questions and more. They conclude: “Except in emergencies, it is advisable to obtain a patient’s informed consent before performing an Internet or social media search for information about the patient or the patient’s family and significant others.”

3888Does a good history include a good google of your patients?

For the second selection, we consider another paper from Psychiatric Services; the authors ask whether telemedicine can help with medication adherence. In this study, the University of Greifswald’s Lara N. Schulze and her co-authors use texting and phone calls. Spoiler alert: the intervention worked.

And a quick request: I’m looking for feedback on the Reading series. Please take a few minutes to complete the (anonymous) online survey:

Note: there will be no Readings for the next two weeks.



Ethics and Practice

“Ethical Considerations Regarding Internet Searches for Patient Information”

Charles C. Dike, Philip Candilis, Barbara Kocsis, Navneet Sidhu, Patricia Recupero

Psychiatric Services, 17 January 2019  Online First

The introduction of Web search engines and their development in the 1990s dramatically changed the landscape of information gathering. With only a few clicks on a computer, cellphone, or other device, an individual can access information on a wide range of topics in a matter of seconds, including personal information about others. To ‘Google’ for information (i.e., to research something via Google or other search engines) has become routine in our daily endeavors. Search engines and social media, such as Facebook, YouTube, Instagram, and so on, provide a ready trove of information on people, events, places, and things. They encourage individuals to post personal information on these sites that can be easily accessed by others.

Physicians are not immune to the allure of social media. A survey of 202 residents and fellows in 2009 showed that 73% of them had a Facebook profile, on which over 90% posted personal information. In another survey of 4,033 physicians, 87% used social media for personal use, and 67% used them for professional activities. In early 2010, 16% of practicing physicians acknowledged having visited a patient’s online profile or that of a patient’s family member, and ‘Googling’ patients (also called ‘patient-targeted Googling’) appears to be growing, more commonly among mental health professionals, even among those in training who feel that such searches are ‘always or usually unacceptable’. Patients and their families (and sometimes other physicians) have reported inappropriate physician communication with patients online, resulting in disciplinary proceedings from medical boards.

uuzezze6vjwthh4gly6eeikhvvzgr96z6ausb4qxrtq8bolohppfxdry9fwmsrtpzotxgwoekky6bo12jfoudtpbxudcmhg6pjketk5rqiny9vu4zgocxxfycipfxCharles C. Dike

So begins a new paper by Dike et al. They consider five aspects of Internet searches.

Quality of Data

The quality of data that one obtains via the Internet is highly variable. Anyone seeking information on the Internet needs to be aware that information can be posted by almost anyone and under such multitudinous circumstances that each item of information needs to be assessed carefully for its reliability and authorship.

They note some advantages, including the observation that some patients are “remarkably open about mental health symptoms on social media…”

Still, they have misgivings: “lack of nonverbal cues, the context of the narrative, the fact that the context may be fluid or changing, the fact that Internet data are often posted with little reflection and represent impulsive communications, that people may be using the Internet to role-play…”

Boundaries, Including Conflicts of Interest

The Internet and social media have contributed to a ‘blurring of boundaries between social and professional spheres’ that can pose special ethical challenges for psychiatrists and other mental health professionals.

The authors note a more complicated relationship when Internet information is used.

Clinton et al. have provided an illustrative clinical vignette involving a psychiatrist whose patient claims to be unable to pay his bill. The psychiatrist looks up the patient’s address on Google Maps, discovers it to be a mansion in a wealthy neighborhood, and confronts the patient about it. As it turns out, the patient is renting a small room in the building in exchange for performing manual labor on the property, and the confrontation severely damages the doctor-patient relationship. The vignette illustrates the complexity of boundary problems that might arise in relation to Googling a patient or researching the patient online.

Safety and Liability

In the event of an emergency or other safety issue, the Internet may be a useful tool. One of the earliest reports in the literature about researching patients online described a case in which an undisclosed previous suicide attempt was discovered when the resident writing a clinical note decided to Google the patient and found a news item about the patient’s serious attempt several months earlier. In the case of an unresponsive or uncooperative patient (e.g., catatonia), searching the patient’s Internet presence or social media activity may enable clinical staff to locate the patient’s relatives for information about drug allergies and current medications.

The authors note that Facebook posts may indicate suicidal thoughts, and other information not readily available to a clinician.

Confidentiality and Privacy

If a psychiatrist locates information about a patient and needs to communicate with the patient or third parties (such as the patient’s family or other treating clinicians) about the content of this information, utmost caution should be exercised with respect to the patient’s privacy and confidentiality.

They wonder, for example, if the sort of information gathered by googling a patient should be added to her or his medical record. 


Psychiatrists should be aware that their own social media and Internet presence may become of interest to their patients. Maintaining a professional Internet presence requires skill and attention. Some have argued that patients should not be allowed to ‘friend’ or ‘like’ a physician’s personal Facebook account but that allowing patients and their families to follow the doctor’s professional account (e.g., the hospital’s Facebook feed) may be useful. However, the risk of befriending a patient on Facebook includes the temptation to subsequently explore or research the patient’s Facebook information and postings.

The authors go on to recommend against Internet or social media searches.

Technology should be used in a way that respects boundaries and confidentiality, and any information obtained through patient-targeted Googling or other targeted Internet searches should be handled with sensitivity regarding the patient’s privacy.


The psychiatrist should consider how the search might influence the clinician-patient relationship, possible risks or benefits of a search, and whether it might advance or compromise treatment.

A few thoughts:

  1. This is an interesting and timely paper.
  1. The authors raise good points. I particularly like the comment about considering a physician’s online presence.

For a patient perspective on this issue, writer Steven Petrow describes how he felt when he found out things about his therapist through social media. See:

  1. The authors are thoughtful, but I’m not sure that they are entirely persuasive. Internet searches are like any other type of information gathering and need to be considered in a larger context. Is safety a concern? Or is google used for a type of (online) voyeurism?
  1. I’ll also note the generational aspect to Internet searches. Last year, working with a couple of colleagues, I co-taught a seminar on social media and psychiatric practice. I was surprised by how quickly and effortlessly my young colleagues tapped social media to understand their patients better.


Meds and Telemedicine

“Improving Medication Adherence With Telemedicine for Adults With Severe Mental Illness”

Lara N. Schulze, Ulrike Stentzel, Jessica Leipert, Josephine Schulte, Jens Langosch, Harald J. Freyberger, Wolfgang Hoffmann, Hans J. Grabe, Neeltje van den Berg

Psychiatric Services, 17 January 2019  Online First

Individuals with schizophrenia or bipolar disorder often experience social isolation, stigmatization, and social decline. Medication nonadherence is a main reason for relapse and hospitalization. Adherence over 12 months among patients taking antipsychotic medications has been estimated at only 50%. Thus interventions to improve medication adherence among patients with severe mental illness are urgently needed.

Telemedicine interventions in the context of schizophrenia and bipolar disorder may offer options to improve adherence to psychotropic medication. Moreover, telemedicine can provide social support while allowing detailed monitoring of these patients without the need for costly face-to-face appointments. Telemedicine concepts range from Web-based support programs to individualized telephone or video calls and smartphone applications. However, only a few telemedicine applications have been developed for individuals with severe mental disorders.

Our group developed a telemedicine concept in 2009 based on standardized telephone calls and text messages for patients with anxiety and mood disorders, and we found positive effects on symptom severity for the intervention group. On the basis of these results, we developed an intervention in a randomized clinical trial that used structured telephone calls for individuals with schizophrenia or bipolar disorder to improve medication adherence.

larastrobelLara N. Schulze

So begins a paper by Schulz et al. It’s a short paper and I quickly summarize it.

Here’s what they did:

  • Participants were recruited from three psychiatric hospitals.
  • They had diagnoses of schizophrenia or bipolar.
  • “After discharge from the hospital, the intervention group received proactive, regular telephone calls every second week for 6 months from three specially trained nurses.” They also received text messages. The material included standardized content, like medication side effects, but also personalized content.

Here’s what they found:

  • A total of 134 were eligible, with 120 participating.
  • Most had schizophrenia (80%).
  • “Logistic regression analysis showed that intervention group participants were significantly more likely than control group participants to be medication adherent at 6 months (odds ratio [OR]=4.11…); the analysis controlled for age, sex, and MARS-D score at baseline.”

This is a small study, and it relies on a self-report scale to measure compliance. Still the authors do a nice job of finding a major problem – non-compliance of medications – and proposing a relatively elegant solution. The phone calls and texts worked.

A few thoughts:

  1. This is a good study.
  1. Let’s not overstate the results – the number of people involved was relatively small.
  1. We often think about how technology lacks the human touch. Here, technology enhances the human touch – literally reaching patients, and encouraging them to take their needed medications.
  1. The authors frame this issue well in their introductory paragraphs. “Medication nonadherence is a main reason for relapse and hospitalization.” And yet half of our patients with severe mental illness are medication noncompliant. Ouch.
  1. Is this intervention cost effective? The brief report doesn’t consider an economic analysis but the costs associated with preventing just one hospitalization would pay for many phone calls and texts.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.