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Internet Filtering Can Hinder Psychiatric Assessment

TO THE EDITOR: The Internet has provided a multitude of benefits to healthcare organizations and other businesses, primarily via enhanced communication and information-sharing. These advantages have been somewhat tempered by nonbusiness-related applications of the Internet that may leave organizations prone to diminished employee efficiency or vulnerable to legal action if offensive material is accessed in the workplace.^1,2 In response, the use of Internet filtering software, including its use in hospitals, has become increasingly common.^2,3 We report a case in which a hospital’s use of Internet filtering impeded the appropriate assessment of a patient, and we discuss the use of Internet filtering in hospitals.

Case Report
"Mr. C," age 18, was brought to the Emergency Department (ED) by police for psychiatric evaluation after it was discovered that he had posted threats (on MySpace.com, a popular Internet social networking site) to kill the assistant principal of his school, other students, and himself.

In the ED, Mr. C admitted to posting threats, but denied any intent to act on them. He acknowledged that he had recently been expelled and was consequently angry with the assistant principal about this. Further questioning revealed previous arrests for aggressive behavior and fire-setting (dating back to age 10), with two periods of probation and 6 months in a residential treatment facility. He denied use of illicit drugs.

Attempts to view the threats were thwarted by the hospital’s Internet filtering system, which indicated that the category "Social Networking and Personal Sites" is filtered. Hospital Information Technology personnel were unable to remove this filter, despite the clinical importance of doing so. After several hours, a hospital computer far from clinical areas was identified that had an unrestricted access to the Internet; and it allowed the viewing of MySpace.com. Mr. C’s page made clear references to drug use (in contradiction to his earlier denial of drug use) and included very detailed and specific threats to various people. With this additional information, Mr. C was admitted to the psychiatry service.

Discussion
Internet filters are used to restrict inappropriate use of the Internet in the workplace, chiefly targeted at websites that may be found offensive or those that are viewed as distractions from work (e.g., online games or video sites). Another focus of Internet filters, as demonstrated in this case, is social networking sites (typified by MySpace.com and Facebook.com). These websites have become ubiquitous, especially among adolescents and young adults, who may use these media as a primary means of communication with peers.⁴

Thorough psychiatric assessment requires the gathering of collateral information, since the patient may not provide complete information to the physician during an interview. Traditionally, this has consisted of contacting family, friends, and outpatient clinicians to discuss the patient’s history and behavior. The Internet, however, with its expanding scope of accessible personal information, is rapidly becoming an important collateral source. Social networking sites allow users to create highly personalized profiles from which a wealth of information about their author can be gleaned. Viewing such a profile offers a unique perspective on the patient. Since users feel as if they are communicating with their peers (as opposed to a physician), and the Internet provides a (perhaps misplaced) sense of anonymity, they may be significantly more forthcoming online with information regarding their social habits than they would be in the context of a structured interview.⁵ As use of social networking sites becomes more common, the gathering of additional information during a psychiatric assessment may include viewing such online content produced by the patient. In the case presented above, this online content was crucial to the overall evaluation of the safety of this patient and the safety of others.

Another unintended result of the use of Internet filters in hospitals is restriction of educational content. Professional organizations (e.g., The Academy of Psychosomatic Medicine) have begun posting various materials online, including videos of educational presentations, patient examinations, and self-assessment tests. If these are posted to sites that are flagged as inappropriate (e.g., a video posted on YouTube.com) they will be blocked, limiting access to an important educational resource.

Internet filtering systems, while intending to restrict recreational or inappropriate use of the Internet, may unintentionally serve as barriers to effective clinical information-gathering and educational material. Hospitals and organizations must carefully weigh the risks and benefits of instituting such measures. Mechanisms by which Internet filters can be overridden (perhaps with a recorded rationale) in cases of clinical or education import may be a useful compromise that should be further explored.

REFERENCES

1. Simmers CA: Aligning internet usage with business priorities. Communications of the ACM 2002; 45:71–74[CrossRef]
2. Greenfield DN, Davis RA: Lost in cyberspace: the web@work. Cyberpsychol Behav 2002; 5:347–353[CrossRef][Medline]
3. Whitty MT: Should filtering software be utilized in the workplace? Australian employees’ attitudes towards Internet usage and surveillance of the Internet in the workplace Surveillance Sociology 2004; 2:39–54
4. Valkenburg PM, Peter J, Schouten AP: Friend networking sites and their relationship to adolescents’ well-being and social self-esteem. Cyberpsychol Behav 2006; 5:584–590
5. Moreno MA, Parks M, Richardson LP: What are adolescents showing the world about their health risk behaviors on MySpace? MedGenMed 2007; 9:9[Medline]

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