This article was downloaded by: [University of Sydney]On: 12 November 2013, At: 18:55Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Technology in Human ServicesPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wths20

Understanding E-Mental HealthResources: Personality, Awareness,Utilization, and Effectiveness of E-Mental Health Resources Amongst YouthXian Long Feng a & Andrew Campbell ba University of Sydney , Earlwood NSW, Australiab The Faculty of Health Sciences, The University of Sydney LidcombeNSW , AustraliaPublished online: 22 Jul 2011.

To cite this article: Xian Long Feng & Andrew Campbell (2011) Understanding E-MentalHealth Resources: Personality, Awareness, Utilization, and Effectiveness of E-Mental HealthResources Amongst Youth, Journal of Technology in Human Services, 29:2, 101-119, DOI:10.1080/15228835.2011.595276

To link to this article: http://dx.doi.org/10.1080/15228835.2011.595276

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Understanding E-Mental Health Resources:Personality, Awareness, Utilization, and

Effectiveness of E-Mental HealthResources Amongst Youth

XIAN LONG FENGUniversity of Sydney, Earlwood NSW, Australia

ANDREW CAMPBELLThe Faculty of Health Sciences, The University of Sydney Lidcombe NSW, Australia

The focus of this study is to replicate portions of the study by Neal,Campbell, Williams, Liu, and Nussbaumer (2011) to determine iftheir findings translate to Australian adolescents. Specifically, thisstudy aims to: determine personality types as predictors of knowl-edge and utilization of e-mental health resources; identify subjectusage rates of specific e-mental health resources; and identifysubject views on the efficacy of these resources. Participants werean opportunistic sample of 1st-year university students (N¼ 176)between the ages of 18 and 25. A single session online surveywas administered. The hypotheses that extroverted adolescentsare less likely to have an awareness of e-mental health resourceswhen compared to neurotic adolescents; and extroverted adoles-cents are less likely to engage in seeking help from e-mental healthresources when compared to neurotic adolescents, were not sup-ported. This study was unable to discern the efficacy of e-mentalhealth resources or the sample’s awareness of e-mental healthresources. However, it was found that the sample was likely toengage in online help seeking behaviour for mental health con-cerns. Despite the limited findings, this study suggests several ideasthat could be further explored.

KEYWORDS depression, e-health, e-mental health, online health

Received April 14, 2011; revised June 4, 2011; accepted June 6, 2011.Address correspondence to Xian Long Feng, University of Sydney, 4A Bass Road,

Earlwood NSW, Australia 2206. E-mail: xfen5586@uni.sydney.edu.au

Journal of Technology in Human Services, 29:101–119, 2011Copyright # Taylor & Francis Group, LLCISSN: 1522-8835 print=1522-8991 onlineDOI: 10.1080/15228835.2011.595276

101

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

DEPRESSION

It is understood that depression is a prominent mental health disorder thataffects people on a global scale. According to the World Health Organization(WHO, 2005), over 450 million people worldwide are affected by mental,neurological, or behavioral problems at any one time, and approximately50% of sufferers do not receive professional help for these problems. Specifi-cally, depression affects approximately 121 million people worldwide, repre-senting one of the leading causes of disability (WHO, 2006). A study byRamklint and Ekselius (2003) found that early onset of major depressive dis-order is significantly more severe and debilitating than onset in later life(where ‘‘early onset’’ was defined as <26 years of age). These findings areconsistent with a previous study conducted by Lewinsohn, Gotlib, and Seeley(1997). In addition, Ramklint and Ekselius also found that early onsetdepression affects the development of personality disorders in later life. Con-versely, personality development has been found to strongly reduce futurevulnerability to depression (Cloninger, Svrakic, & Przybeck, 2006). Thesefindings suggest that treating depression in youth is of paramount impor-tance. Depression is known as a mood disorder, whereas anxiety (a charac-teristic of the neuroticism personality trait) is an affective disorder. Bothhigher- and lower-order neuroticism (i.e., hostility and anxiety) are linkedwith an increased risk for depression (Clara, Cox, & Enns, 2003). Essentially,depression and personality impact upon each other. The relationshipbetween these two disorders is best summarized by Hansenne and Bianchi(2009):

The relationship between personality and depression is extremely com-plex: personality features may predispose an individual to depression;the personality can be modified after a depression; the personality canmodify the clinical presentation of a depressive disorder; and finallythe personality can be conceptualised as a subclinical manifestation ofa depressive disorder. (p. 63)

Due to this reciprocal relationship, neuroticism is often closely examinedwhen investigating depression and vice versa.

Barriers to Treatment and Solutions

Barriers to conventional treatment for depression may include affordability, ashort supply of healthcare services or clinicians, inconvenience in terms ofconflicting working hours or social stigmas associated with mental healthdisorders (Lissman & Boehnlein, 2001; Perini, Titov, & Andrews, 2009). Inaddressing these barriers, attention has shifted to the Internet in developinge-health resources. Eysenbach (2001) describes e-health as ‘‘. . . an emerging

102 X. L. Feng and A. Campbell

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

field in the intersection of medical informatics, public health and business,referring to health services and information delivered or enhanced throughthe Internet and related technologies.’’ (Stjernsward & Ostman, 2006, p. 698).E-mental health resources (e.g., psychoeducation, self-help tools, onlinecounseling, etc.) possess several unique advantages over traditional therapiessuch as maintaining anonymity, improved accessibility in terms of overcom-ing geographical constraints, as well as the flexibility of accessing treatmentat any time. A further advantage is that users can dictate the degree ofaccessibility; which in turn gives them the ability to review material asdesired.

At this point, it is cautioned that online mental health resources are notto be viewed as an all-encompassing solution to accessibility and improve-ment of engagement with mental health information or service. For instance,it is difficult to target the right audience and any negative user outcomes maybe unnoticed. Hausner, Hajak, and Spiebl (2008) state that although e-mentalhealth resources are useful, merely making them available does not necessar-ily result in their utilization. In contrast, people who do seek online help formental health concerns are not always met with appropriate treatment oruseful information as the quality of online information is generally poor(Griffiths & Christensen, 2000; Lissman & Boehnlein, 2001; Titov et al., 2010).Clearly, connecting users to appropriate e-mental health resources is not assimple as it seems.

These findings are paralleled by the fact that dropout rates for Internet-based interventions for depression are staggeringly high, regardless of howit is delivered (Mackinnon, Griffiths, & Christensen, 2008). Christensen,Griffiths, Mackinnon, and Brittliffe (2006) note, ‘‘Attrition from open accessnon-tracked websites can be high, with as little as 1% of users completinga full course of online therapy’’ (p. 1737). A study by Clarke and colleagues(2005) found that reminders were a significant factor in determining retentionand effectiveness. Weekly reminders through e-mail, telephone calls, or briefface-to-face meetings were found to dramatically improve retention rates(Christensen et al., 2006). Similarly, a study by Christensen, Griffiths, Korten,Brittliffe, & Groves (2004) observed that weekly tracking of users, for thecognitive behavior therapy website MoodGYM, increased retention rateswhen compared to those accessing MoodGYM from the World Wide Web.It is important to understand that high dropout rates do not necessarily meanan intervention is inefficacious. Christensen et al. (2006) reasons that drop-outs may be attributed to user dependent factors such as differingapproaches to treatment, for example, seeking a full programmatic treatment,stand-alone information, meeting specific goals, or to experiment withtreatment.

The general consensus is that computerized cognitive behavioral ther-apy (CCBT), or Internet-based variants of it (iCBT), is the most salient ofe-mental health resources in terms of treatment outcome. This is reflected

Understanding E-Mental Health Resources 103

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

through extensive randomized control trials and comparative randomizedtrials investigating the efficacy of this particular e-mental health resource,particularly in treating mild-to-moderate depression (Christensen, Griffiths,& Jorm, 2004; Christensen et al., 2006; Mackinnon et al., 2008; Perini et al.,2009; Titov et al., 2010; Vernmark et al., 2010). In spite of all this research,the mechanisms behind this treatment are not well understood (Vernmarket al., 2010). Indeed, the development and utilization of e-mental healthresources is not as straightforward as it seems.

E-mental health resources specifically targeting gaps in mental healthservices for youth have been developed for more than 15 years; namely tomotivate them to seek help from general practitioners or specialists byempowering them with easy-to-find and easy-to-access online information(McMullan, 2006). Although there is strong evidence supporting the use ofthe Internet as a medium in delivering health interventions for depression(Neal et al., 2011; Perini et al., 2009; Sethi, Campbell, & Ellis, 2010; Speket al., 2007; Vernmark et al., 2010), the troublesome aspect is that researchon the efficacy of these online resources and their intended motives toempower youth to seek help, have been poorly investigated (Griffiths,Calear, & Banfield, 2009a, 2009b; Borzekowski, 2006). Data obtained by Nealet al. in a Canadian study (N¼ 1300), demonstrated that adolescents, ages18–25, are highly unaware of how to accurately seek help online for mentalhealth concerns, as well as engage in efficacious programs that are promotedonline (e.g., online counseling). Neal et al. found that information retrievalskills, as well as basic understanding of mental health problems in thiscohort, was extremely poor.

The current study replicated portions of the study by Neal et al. (2011)to determine if these findings translate to Australian adolescents. Specifi-cally, the current study administered an end-user survey with the aim ofdetermining personality types as predictors of knowledge and utilizationof e-mental health resources; identifying subject usage rates of specifice-mental health resources; and identifying subject views on the efficacyof these resources. Through the survey, it was predicted that psycho-education (i.e., websites containing dense literature on mental health andtreatment options) is not empowering (i.e., motivating) youth to seekfurther help; and youth are unaware of alternative e-mental healthresources for specific issues (e.g., iCBT, support groups, and serious gamesfor specific mental health issues). Considering that high levels of extraver-sion is negatively correlated with depression and feelings of hopelessness;and high levels of neuroticism are positively correlated with depression andfeelings of hopelessness (Chioqueta & Stiles, 2005); it was theorized thatneurotic personality types are more aware of e-mental health resourcesfor depression and anxiety when compared to extroverted personalitytypes. As such, it was presumed that they are more willing to engage withthese resources.

104 X. L. Feng and A. Campbell

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

Based on current literature, this explorative study hypothesized thatextroverted adolescents (as measured by the Eysenck Personality Question-naire [EPQ-R]) are less likely to have an awareness of e-mental healthresources when compared to neurotic adolescents; and extroverted adoles-cents are less likely to engage in seeking help from e-mental health resourceswhen compared to neurotic adolescents. From this, the pilot data from theNeal et al. (2011) study and the current study will be used for further inves-tigation in how to improve access to and improve e-mental health servicesfor adolescents globally.

METHOD

Participants

An opportunistic sample population was recruited through the University ofSydney, 1st-year Health Science students, ages 18–25. In addition, the pri-mary investigator also recruited a small external sample enrolled outside ofthe aforementioned subjects (n¼ 11). Only those students who were fluentin English were able to participate in the study. This is due to the study beingrun at an English-speaking higher education institution, which requires alevel of competency in English to enroll. Furthermore, online informationregarding mental health resources was delivered in English. This studygained approval from the University of Sydney’s Human Ethics ResearchCommittee.

Sample Size

A total of 214 people volunteered to participate, however, data of only 176participants was used in the present analysis. Data of 38 participants wereexcluded because they submitted incomplete surveys or withdrew in themiddle of completing their surveys (n¼ 31) or because they did not fulfillthe age criteria (older than 25, n¼ 6; younger than 18, n¼ 1). An alpha coef-ficient of 0.05 was desired, necessitating a minimum sample size of at least 50participants.

Procedures

Students were informed about the research project through specific 1st-yearunits of study run in second semester, 2010. Students were given an option toparticipate in the study, voluntarily, for credit of 5% of their course workmark. For those students who did not wish to participate, they were offeredan alternative 5% assessment comprising of a 500-word report on the accessi-bility and efficacy of e-mental health information and resources for adoles-cents. Study participants were directed by advertisements and short verbal

Understanding E-Mental Health Resources 105

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

notifications in class, as well as with unit of study assessment guidelines, onhow to take part in the online survey. Specifically, participants were directedeither through student e-mail or WebCT to the online survey portal for thestudy. Participants were informed that they could withdraw from the studyat any time without prejudice or penalty. All participants were unidentifiedvia the adoption of a participant number.

The online survey was created using a Faculty of Health Sciences licensefor Survey Monkey, which ensures 128-bit encryption of the data that is onlyaccessible by the researchers for raw data viewing and analysis. There wasno time limit in completing the online survey. Data was obtained throughone survey session from each participant. Consent was assumed uponsubmission of the survey. Feedback of the study results were delivered inlectures toward the end of semester two, 2010, as well as through a one-pagereport posted on the survey website and that of WebCT for the specific unitsof study where students were recruited. Data in the feedback report (and thisreport) was nonidentifiable for participants.

Measures

The online survey contains 54 items, comprising of demographics questionssuch as age and gender, as well as topic specific items about the participant’suse of e-mental health information and resources, which were drawn fromthe same 2010 study by Neal et al. (see Appendix). Incorporated into the54-item survey is a normative standardized personality questionnaire, theEysenck Personality Questionnaire, revised short scale of 48 items (EPQ-R;Eysenck, Eysenck, & Barrett, 1985). This scale was selected due to its robustmeasure of the personality traits psychoticism, extraversion, and neuroticismand a lie scale, each of which has been tested for reliability and validityagainst the NEO Personality Inventory (Draycott & Kline, 1995).

Statistical Analysis

Data was analysed using SPSS Statistical Software, version 19. Specificanalysis involved descriptive statistics and correlation analysis using Pearsoncorrelations and point biserial correlations. Point biserial correlations werealso employed as it allowed for the identification of the strength of correla-tions between a dichotomous variable and continuous variables (Portney &Watkins, 2008). No Bonferroni adjustments were made.

RESULTS

A total of 176 participants were examined in this study; 32% (n¼ 57) weremale and 68% (n¼ 119) were female. The average age of the population

106 X. L. Feng and A. Campbell

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

was 19.34 (SD: 1.75), with a minimum and maximum age of 18 and 25respectively. This sample was characterized by mild psychoticism (n¼ 174),high extraversion (n¼ 126) and evenly distributed neuroticism. Specifically,27% (n¼ 47) were rated mildly neurotic; 44% (n¼ 78) moderately neurotic;and 29% (n¼ 51) highly neurotic. It was also noted that females in this sam-ple were significantly correlated with neuroticism (r¼ .18, p< .05).

As denoted in Table 1, based on the mean scores from responses of 1(not likely), 2 (somewhat unlikely), 3 (somewhat likely), and 4 (very likely);preferences for online resources from most to least preferred were:(a) text-based search engines (x¼ 2.95); (b) informational site (x¼ 2.15);(c) Facebook or Myspace profiles (x¼ 2.14); (d) one-on-one psychologistcontact via an Internet technology (x¼ 2.11); (e) online support groups=discussion boards (x¼ 1.96); (f) self-directed online therapy (x¼ 1.77);(g) online health games (x¼ 1.72); (h) psychologist led online group chat(x¼ 1.61); and (i) visual search engine (x¼ 1.52).

Almost half of participants (44%) reported they had used the Internet atsome point in time to learn about personal feelings of anxiety, sadness, orconfusion. Participant-usage rates of online resources for the purpose ofcoping with feelings were distributed as follows: (a) 42% used text-basedsearch engines, (b) 26% used informational sites, (c) 22% used Facebookor Myspace profiles, and (d) 11% used online support groups=discussionboards. All other e-mental health resources were used by less than 5% ofparticipants. There were no online resources that were not utilized by thissample. It was noted that some participants might have used more thanone online resource.

Fifty-nine percent of participants reported that online resources thatthey had used ‘‘didn’t make things better or worse,’’ 40% reported ‘‘theyhelped a little,’’ and only 1% of participants reported ‘‘they helped a lot.’’

TABLE 1 The Likelihood of Using Various Online Resources if Needed (%)

Not likely–1 Somewhat unlikely–2 Somewhat likely–3 Very likely–4

A 33 (n¼ 59) 28 (n¼ 49) 29 (n¼ 51) 10 (n¼ 17)B 12 (n¼ 21) 14 (n¼ 24) 42 (n¼ 74) 32 (n¼ 57)C 63 (n¼ 110) 24 (n¼ 43) 12 (n¼ 21) 1 (n¼ 2)D 58 (n¼ 101) 27 (n¼ 48) 12 (n¼ 21) 3 (n¼ 6)E 49 (n¼ 86) 27 (n¼ 48) 22 (n¼ 38) 2 (n¼ 4)F 40 (n¼ 71) 29 (n¼ 51) 25 (n¼ 44) 6 (n¼ 10)G 51 (n¼ 90) 28 (n¼ 50) 18 (n¼ 31) 3 (n¼ 5)H 38 (n¼ 68) 22 (n¼ 38) 27 (n¼ 48) 13 (n¼ 22)I 37 (n¼ 64) 27 (n¼ 48) 25 (n¼ 44) 11 (n¼ 20)

N¼ 176, A¼ Information Site, B¼Text-based Search Engine, C¼Visual Search Engine, D¼Psychologist

led online group chat, E¼ Self-directed Online Therapy, F¼Online Support Group=Discussion Board,

G¼Online Health Games, H¼ Facebook or Myspace profiles, I¼One-on-one psychologist contact via

an Internet technology.

Understanding E-Mental Health Resources 107

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

No participants reported that the online resources ‘‘made things worse’’ or ‘‘alittle worse.’’ As such, responses were dichotomized for the survey item; ‘‘Ingeneral, did the online resource you used help you deal with your feelings?’’and point biserial correlations were conducted to reveal any relationshipwith extraversion and neuroticism. Surprisingly, no significant relationshipwas found for either extraversion (rpbis¼ 0.11, p> .05) or neuroticism(rpbis¼ 0.02, p> .05).

Pearson correlations revealed no significant relationship between extra-version and the likelihood of using online resources if needed; (a) informationsite (r¼ 0.02, p> .05), (b) text-based search engine (r¼�0.03, p> .05), (c) vis-ual search engine (r¼ 0.02, p> .05), (d) psychologist led online group chat(r¼�0.03, p> .05), (e) self-directed online therapy (r¼ 0.07, p> .05), (f)online support groups=discussion boards (r¼ 0.04, p> .05), (g) online healthgames (r ¼�0.01, p> .05), (h) Facebook or Myspace profiles (r¼ 0.11,p> .05), and (i) one-on-one psychologist contact via an internet technology(r¼ 0.12, p> .05). Furthermore, no significant relationship was observedbetween extraversion and having ever used the Internet to learn aboutanxious, sad, or confused feelings (r¼ 0.06, p> .05); or previous usage ofonline resources to cope with feelings (r¼ 0.01, p> .05). The only significantcorrelation between neuroticism and the likelihood of using online resources ifneeded was for online health games (r¼�0.24, p< .05). A significant relation-ship was found when neuroticism was compared to Internet usage to learnabout anxious, sad, or confused feelings (r¼�0.23, p< .05); but no relation-ship was found when compared to previous usage of online resources to copewith feelings (r¼ 0.03, p> .05).

Despite the large amount of correlation analysis that was conducted, noBonferroni corrections were carried out. A full or partial Bonferroni correc-tion would have been impractical in that the chances of type II errors occur-ring would be highly probable. Thus, it was deemed most suitable to notcarry out any Bonferroni corrections. As such, it should be noted that thechances of a type I error occurring in this study is increased.

DISCUSSION

Based on these results, neither hypothesis was supported. The relationshipsbetween e-mental health resources and extraversion and neuroticism wereseemingly nonsignificant or contradictory. Extroverted adolescents werenot found to have less of an awareness of e-mental health resources thanneurotic adolescents; neither were extroverted adolescents found to be lesslikely to engage in seeking help from e-mental health resources than neuroticadolescents.

Firstly, the results suggest that extroverted and neurotic adolescentswere both unlikely to have a good awareness of e-mental health resources.

108 X. L. Feng and A. Campbell

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

This is unsurprising for extroverted adolescents as high extraversion reflectsinternal control and a strong positive affect intensity (Barrio, Moreno-Rosset,Lopez-Martinez, & Olmedo, 1997). This is representative of extroverts havinga low risk for depression as well as the fact that they would not perceivethemselves as needing help. As such, they would not be familiar withe-mental health resources in general. As for neurotic adolescents, contraryto earlier presumptions, exhibiting depressive symptoms and feelings ofhopelessness does not necessarily translate to having a good knowledge ofe-mental health resources. Given the available data, it is impossible to deter-mine extraversion and neuroticism as reliable predictors of awareness fore-mental health resources.

Regardless, these findings are consistent with those of Neal et al.’s(2011) study where adolescents were observed to be highly unaware ofhow to accurately seek help online for mental health concerns. This pointis further substantiated by the current sample’s limited preference fortext-based search engines and information sites, representing the same trendin Neal et al.’s study. Although there is a preference for these two onlineresources, the current sample does not seem to find them to be efficacious.Indeed, as noted by Hausner et al. (2008), this study demonstrates thatmerely making e-mental health resources available does not necessarilyresult in their utilization, nor is utilization necessarily efficacious. A possibleexplanation for the preference may simply be the fact that text-based searchengines and information sites are the main online resources that adolescentsare aware of, thus ranking them highly by default. Another potential expla-nation may be due to the fact that Internet users of all ages and levels of edu-cation generally have short attention spans (Lissman & Boehnlein, 2001).This fact may inadvertently affect the way in which adolescents search forinformation about mental health, such as opting for online resources thatare brief, only browsing the first few results of a search or reading only aparagraph of information. If this is true, the importance of creating and main-taining user engagement is further emphasized. It is interesting to note thatFacebook and Myspace profiles were the next most preferred e-mentalhealth resource. Specifically, it was ranked higher than online supportgroups or discussion boards. This may be attributed to different elementscharacteristic of each online resource. That is, social networks and onlineprofiles are private environments that offer users a certain level of controland privacy whilst online support groups and discussion boards are public,ungoverned, or governed by unknown or unfamiliar moderators. Although itmay not be apparent at first, Facebook possesses the utility and functionalityto serve as an e-mental health resource. This is due to the fact that it eclipsesmany features of more traditional online resources (e.g., forums and chat-rooms). Coupled with the prominence of Facebook ‘‘groups’’ and statusupdates, the social networking site can serve as a means to publicize andconnect individuals to relevant health-care services.

Understanding E-Mental Health Resources 109

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

Secondly, it was found that extroverted and neurotic adolescents wereboth unlikely to engage in seeking help from e-mental health resources. Thisis not surprising if we consider the previous finding that both extroverted andneurotic adolescents were unaware of e-mental health resources. That is,online help cannot be sought if individuals are unaware of what to searchfor in the first place. It was also found that the more neurotic an individualwas, the less likely they were to engage in seeking online help. This is alsounderscored by the finding that neurotic individuals exhibited a strong aver-sion to online health games. It is noted that this sample was predominantlyfemale, and females were shown to be more neurotic than males, as is con-sistent with past literature (Goodwin & Gotlib, 2004).

Another explanation as to why neither extroverts nor neurotics werelikely to engage in seeking online help might be that adolescents do not pos-sess the mindset in viewing online resources as a viable resource, contrary tothe perceived merits and advantages the Internet has to offer. Although thereare studies that lend support for the Internet being a viable tool in deliveringmental health resources, a large majority of them were conducted with non-adolescent samples or samples with a wide age range (Christensen, Griffiths,& Jorm, 2004; Christensen et al., 2006; Mackinnon et al., 2008; Perini et al.,2009; Titov et al., 2010; Vernmark et al., 2010). Based on these aforemen-tioned studies, it is often assumed that adolescent users will be of the samemindset towards using e-mental health resources. A 2004 press release fromKids Help Line showed that online counseling sessions increased by 8,000 to21,578 when compared to the previous year (although the age ranges werenot stated). This is sharply contrasted with the current samples lack of aware-ness or nonpreference toward online counseling sessions. A possible reasonas to why this sample is unlikely to engage in seeking help from e-mentalhealth resources may be attributed to characteristics of the ‘‘Millenial gener-ation’’ stereotype (also known as Generation Y), as mentioned in Neal et al.’s(2011) study. To extend upon this point, adolescents may possibly perceivethe more ‘‘traditional’’ online resources as outdated and=or irrelevant. Thiswould certainly be one way to explain their preference toward the relativelynewer online resources such as Facebook.

This study suffers from several shortcomings. The sample was oppor-tunistic in nature and was drawn from 1st-year university Health Science stu-dents. The study’s sample was also predominantly female (68%). As such,population generalizability is limited in that it is not representative of acommunity sample. In addition, the sample’s personality orientation maybe unnaturally skewed towards neuroticism due to the prominence offemales. Another potential limitation is the fact that offering grade pointsfor participation may skew answers. Given the academic setting, it is possiblethat participants may feel inclined to answer ‘‘favorably’’ to provide the inves-tigator with the ‘‘correct’’ results=impressions despite being clearly informedof the confidentiality of answers. This study also did not account for potential

110 X. L. Feng and A. Campbell

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

personality overlaps, such as psychotic extroverts or psychotic neurotics.Lastly, and perhaps the most glaring flaw, is within the survey design. Asidefrom EPQ-R items, all of the survey items were drawn, unaltered, from Nealet al.’s (2011) study. In retrospect, the questions were inadequately wordedto properly investigate the current hypotheses. That is, there were severalissues associated with the participant’s interpretation of questions. Firstly,the question ‘‘If you were going through a difficult time in your life, howlikely is it that you would visit the following types of online resources?’’did not clearly state whether the online resources were endorsed by a legit-imate health organization or governing body, as this may have been a factorinfluencing participant responses. In addition, this question could not accu-rately discern whether the respondent knew about the listed e-mental healthresources, or had used a resource, prior to answering. Essentially, thisquestion was not an accurate detector of e-mental health resource aware-ness. There were also dimensional limitations within survey responses.Specifically, for the question ‘‘In general, did the online resources you usedhelp you deal with your feelings?’’ there was no suitable response option forparticipants who had never utilized any online resource for health. As such,there is a possibility for skewed responses, where the result would be anoverestimation of participant usage of online resources. This would in turnimpact on the point biserial correlations between this survey item with extra-version and neuroticism. If this shortcoming was accounted for, a potentialsignificant relationship may be found between e-mental health resourceefficacy and neuroticism. In addition, this question was not specific in itsreference to ‘‘online resources’’ in that it was unclear whether it embodiedthe survey’s aforementioned list of e-mental health resources or perhapsan unlisted online resource that the participant had engaged with, meaningrelationships between e-mental health resource preference and efficacycould not be established.

FUTURE RESEARCH

This study concludes that psychoeducation websites were not empoweringyouth in seeking help, and neither were youth aware of alternative e-mentalhealth resources outside that of text-based search engines and informationsites. Specifically, extroverted adolescents were not found to have less ofan awareness of e-mental health resources than neurotic adolescents; neitherwas extroverted adolescents found to be less likely to engage in seeking helpfrom e-mental health resources than neurotic adolescents. As discouragingand limited the current findings may seem, this study suggests severalideas and angles that could be further explored. It is reminded that anyreplication should take note of and address the previously outlined methodo-logical flaws.

Understanding E-Mental Health Resources 111

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

Firstly, the current study could be conducted with a nonuniversity sam-ple and=or a non-Australian sample. A non-Australian sample, particularly anonwestern one, may offer insight into whether cultural factors have anyimpact on the preference or usage of e-mental health resources. Perhaps cul-tures where there is a greater social stigma towards mental illness translatesto greater utilization of certain e-mental health resources. If so, future devel-opment of e-mental health resources may need to account for culturaldifferences amongst their potential userbase.

Subsequent research could focus on identifying individual popular=desirable features within preferred online resources so that they may be com-bined synergistically to create a truly unique e-mental health resource, ratherthan the traditional approach of integrating mental health elements into exist-ing forms of online resources. Barak, Hen, Boniel-Nissim, and Shapira (2008)touched upon this idea by identifying some of these features, such as method(e.g., human communication or self-help); mode (e.g., textual, audio, video);and execution (e.g., synchronously or asynchronously). Understanding theaffect these factors have on the user, as well as one another, is importantbecause the structural aspect of e-mental health resources often underpinsthe effectiveness of the mechanism(s) it employs, for example, text-basedonline counseling in the form of chat compared to audio visual online coun-seling in the form of webcam conversations.

Future research can also replicate the current study for clinicallydepressed individuals to further investigate the relationship between neuroti-cism and depression. Understanding the efficacy of e-mental health resourceson different stages of depression will allow health professionals to prescribeit more appropriately.

In saying that, this study reaffirms that e-mental health resourcesshould not be perceived or used as a complete substitute for traditionalface-to-face therapies. E-mental health resources should be used as asupplement until the efficacy and mechanisms behind it are betterunderstood.

REFERENCES

Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A comprehensive reviewand a meta-analysis of the effectiveness of internet-based psychotherapeuticinterventions. Journal of Technology in Human Services, 26(2), 109–160. doi10.1080=15228830802094429

Barrio, V. D., Moreno-Rosset, C., Lopez-Martinez, R., & Olmedo, M. (1997). Anxiety,depression and personality structure. Personality and Individual Differences,23(2), 327–335. doi: 10.1016=S0191-8869(97)00030-5

Borzekowski, D. L. (2006). Adolescents’ use of the Internet: A controversial, coming-of-age resource. Adolescent Medicine Clinics, 17(1), 205–216.

112 X. L. Feng and A. Campbell

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

Chioqueta, A., & Stiles, T. C. (2005). Personality traits and the development ofdepression, hopelessness, and suicide ideation. Personality and IndividualDifferences, 38, 1283–1291. doi: 10.1016=j.paid.2004.08.010

Christensen, H., Griffiths, K. M., & Jorm, A. F. (2004). Delivering interventions fordepression by using the Internet: Randomised controlled trial. British MedicalJournal, 328, 1–5. doi: 10.1136=bmj.37945.566632.EE

Christensen, H., Griffiths, K. M., Korten, A. E., Brittliffe, K., & Groves, C. (2004). Acomparison of changes in anxiety and depression symptoms of spontaneoususers and trial participants of a cognitive behaviour therapy website. Journalof Medical Internet Research, 6, e46. doi: 10.2196=jmir.6.4.e46

Christensen, H., Griffiths, K. M., Mackinnon, A. J., & Brittliffe, K. (2006). Onlinerandomised controlled trial of brief and full cognitive behaviour therapy fordepression. Psychological Medicine, 36, 1737–1746. doi: 10.1017=S0033291706008695

Clara, I. P., Cox, B. J., & Enns, M. W. (2003). Hierarchical models of personality andpsychopathology: The case of self-criticism, neuroticism, and depression.Personality and Individual Differences, 35, 91–99.

Clarke, G., Eubanks, D., Reid, E., Kelleher, C., O’Connor, E., DeBar, L. L., Lynch, F.,Nunley, S., & Gullion, C. (2005). Overcoming depression on the Internet (ODIN)(2): A randomized trial of a self-help depression skills program with reminders.Journal of Medical Internet Research, 7, e16. doi: 10.2196=jmir.7.2.e16

Cloninger, C. R., Svrakic, D. M., & Przybeck, T. R. (2006). Can personality assessmentpredict future depression? A twelve-month follow-up of 631 subjects. Journal ofAffective Disorders, 92, 35–44. doi: 10.1016=j.jad.2005.12.034

Draycott, S. G., & Kline, P. (1995). The Big Three or The Big Five – the EPQ-R vs theNEO-PI: A research note, replication and elaboration. Personality and Individ-ual Differences, 18(6), 801–804. doi: 10.1016=0191-8869(95)00010-4

Eysenck, S. B. G., Eysenck, H. J., & Barrett, P. (1985). A revised version of the psy-choticism scale. Personality and Individual Differences, 6(1), 21–29.

Eysenbach, G. (2001). What is e-health? Journal of Medical Internet Research, 3, e20.Retrieved from http://jmir.org/2001/2/e20/. doi: 10.2196/jmir.3.2.e20

Goodwin, R. D., & Gotlib, I. H. (2004). Gender differences in depression: The role ofpersonality factors. Psychiatry Research, 126, 135–142. doi: 10.1016=j.psychres.2003.12.024

Griffiths, K. M., Calear, A. L., & Banfield, M. (2009a). Systematic review on InternetSupport Groups (ISGs) and depression (1): Do ISGs reduce depressive symp-toms? Journal of Medical Internet Research, 11(3), 40.

Griffiths, K. M., Calear, A. L., & Banfield, M. (2009b). Systematic review on InternetSupport Groups (ISGs) and depression (2): What is known about depressionISGs? Journal of Medical Internet Research, 11(3), 41.

Griffiths, K. M., & Christensen, H. (2000). Quality of web based information ontreatment of depression: cross sectional survey. British Medical Journal, 321,1511–1515.

Hausner, H., Hajak, G., & Spiebl, H. (2008). Gender Differences in Help-SeekingBehavior on Two Internet Forums for Individuals with Self-ReportedDepression. Gender Medicine, 5, 181–185. doi: 10.1016=j.genm.2008.05.008

Understanding E-Mental Health Resources 113

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

Hansenne, M., & Bianchi, J. (2009). Emotional intelligence and personality in majordepression: Trait versus state effects. Psychiatry Research, 166, 63–68. doi:10.1016=j.psychres.2008.03.015

Kids Help Line (2005). Epidemic of Kids Self Harming: Kids Help Line release 2004stats. Retrieved from http://www.kidshelp.com.au/upload/12160.pdf

Lewinsohn, P. M., Gotlib, I. H., & Seeley, J. R. (1997). Depression-related psycho-social variables: Are they specific to depression in adolescents? Journal ofAbnormal Psychology, 106, 365–357.

Lissman, T., & Boehnlein, J. K. (2001). A critical review of Internet information aboutdepression. Psychiatric Services, 52, 1046–1050.

Mackinnon, A., Griffiths, K. M., & Christensen, H. (2008). Comparative randomisedtrial of online cognitive-behavioural therapy and an information website fordepression: 12-month outcomes. The British Journal of Psychiatry, 192,130–134. doi: 10.1192=bjp.bp.106.032078

McMullan, M. (2006). Patients using the Internet to obtain health information: Howthis affects the patient-health professional relationship. Patient Education &Counseling, 63, 24–28.

Neal, D. M., Campbell, A. J., Williams, L. Y., Liu, Y., & Nussbaumer, D. (2011). ‘‘I didnot realize so many options are available’’: Cognitive authority, emerging adults,and e-mental health. Library & Information Science Research, 33, 25–33. doi:10.1016=j.lisr.2010.07.015

Perini, S., Titov, N., & Andrews, G. (2009). Clinician-assisted Internet-based treat-ment is effective for depression: Randomized controlled trial. Australian andNew Zealand Journal of Psychiatry, 43, 571–578.

Portney, L. G., & Watkins, M. P. (2008). Foundations of clinical research applicationsto practice, (3rd ed.). Saddle River, NJ: Pearson Prentice Hall.

Ramklint, M., & Ekselius, L. (2003). Personality traits and personality disorders inearly onset versus late onset major depression. Journal of Affective Disorders,75, 35–42. doi: 10.1016=S0165-0327(02)00028-9

Sethi, S., Campbell, A. J., & Ellis, L. A. (2010). The use of computerized self-help packages to treat adolescent depression and anxiety. Journal ofTechnology in Human Services, 28(3), 144–160. doi: 10.1080=15228835.2010.508317

Spek, V., Cuijpers, P., Nyklicek, I., Riper, H., Keyzer, J., & Pop, K. (2007).Internet-based cognitive behaviour therapy for symptoms of depression andanxiety: A meta-analysis. Psychological Medicine, 37, 319–328. doi: 10.1017=S0033291706008944

Stjernsward, S., & Ostman, M. (2006). Potential of e-health in relation to depression:Short survey of previous research. Journal of Psychiatric and Mental HealthNursing, 13, 698–703.

Titov, N., Andrews, G., Davies, M., McIntyre, K., Robinson, E., & Solley, K. (2010).Internet treatment for Depression: A randomized controlled trial comparingclinician vs. technician assistance. PloS ONE, 5, 1–9. doi: 10.1371=journal.pone.0010939

Vernmark, K., Lenndin, J., Bjarehed, J., Carlsson, M., Karlsson, J., Oberg, J., . . .Andersson, G. (2010). Internet administered guided self-help versusindividualized e-mail therapy: A randomized trial of two versions of CBT for

114 X. L. Feng and A. Campbell

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

major depression. Behaviour Research and Therapy, 48, 368–376. doi: 10.1016=j.brat.2010.01.005

World Health Organization. (2005). WHO sites: Mental health. Retrieved fromwww.who.int/mental_health/en/

World Health Organization. (2006). Depression. Retrieved from http://www.who.int/topics/depression/en/

APPENDIX

Survey Questions

1) What is your gender?

a. Femaleb. Male

2) How old are you?

a. 18b. 19c. 20d. 21e. 22f. 23g. 24h. 25

3) If you were going through a difficult time in your life, how likely is it thatyou would visit the following types of online sources?1 – Not likely, 2 – somewhat unlikely, 3 – somewhat likely, 4 – Verylikely

a. A site with some information to read, such as http://www.nlm.nih.gov/medlineplus/depression.htm

b. A text-based search engine, such as http://www.google.comc. A visual search engine, such as http://www.kartoo.comd. A group online chat session led by a psychologist, such as http://

www.psychcentral.com/chats.htme. A self-directed online therapy program, such as http://moodgym.

anu.edu.auf. Online support groups or discussion boards, such as http://

forums.psychcentral.com/

Understanding E-Mental Health Resources 115

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

g. Online games that have help built into them, such as http://www.reachoutcentral.com.au/register.asp

h. Facebook or MySpace profiles, such as http://www.myspace.com/nycteen_mindspace

i. One-on-one online contact with a psychologist, using aninternet technology such as email, instant messaging, online chat orvideo call

4) Have you ever felt anxious, sad, or confused, and then used the internetto learn about these feelings? Y=N

5) Which of the following did you use in the past to help you with yourfeelings? Please select all that apply.a. A site with some information to read, such as http://www.nlm.nih

.gov/medlineplus/depression.htmb. A text-based search engine, such as http://www.google.comc. A visual search engine, such as http://www.kartoo.comd. A group online chat session led by a psychologist, such as http://

www.psychcentral.com/chats.htme. A self-directed online therapy program, such as http://moodgym.

anu.edu.auf. Online support groups or discussion boards, such as http://forums.

psychcentral.com/g. Online games that have help built into them, such as http://www.

reachoutcentral.com.au/register.asph. Facebook or MySpace profiles, such as http://www.myspace.com/

nycteen_mindspacei. One-on-one online contact with a psychologist, using aninternet technology such as email, instant messaging, online chat orvideo call

6) In general, did the online resource you used help you deal with yourfeelings?a. No, they made things worseb. No, they made things a little worsec. They didn’t make things either better or worsed. Yes, they helped a littlee. Yes, they helped a lot

7) Does your mood often go up and down? Y=N

8) Do you take much notice of what people think? Y=N

116 X. L. Feng and A. Campbell

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

9) Are you a talkative person? Y=N

10) If you say you will do something, do you always keep your promise nomatter how inconvenient it might be? Y=N

11) Do you ever feel ‘just miserable’ for no reason? Y=N

12) Would being in debt worry you? Y=N

13) Are you rather lively? Y=N

14) Were you ever greedy by helping yourself to more than your share ofanything? Y=N

15) Are you an irritable person? Y=N

16) Would you take drugs which may have strange or dangerous effects?Y=N

17) Do you enjoy meeting new people? Y=N

18) Have you ever blamed someone for doing something that was reallyyour fault? Y=N

19) Are your feelings easily hurt? Y=N

20) Do you prefer to go your own way rather than act by the rules? Y=N

21) Can you usually let yourself go and enjoy yourself at a lively party? Y=N

22) Are all your habits good and desirable ones? Y=N

23) Do you often feel ‘fed-up’? Y=N

24) Do good manners and cleanliness matter much to you? Y=N

25) Do you usually take the initiative in making new friends? Y=N

Understanding E-Mental Health Resources 117

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

26) Have you ever taken anything (even a pin or button) that belonged tosomeone else? Y=N

27) Would you call yourself a nervous person? Y=N

28) Do you think marriage is old fashioned and should be done anotherway? Y=N

29) Can you easily get some life into a rather dull party? Y=N

30) Have you ever broken or lost something belonging to someone else?Y=N

31) Are you a worrier? Y=N

32) Do you enjoy co-operating with others? Y=N

33) Do you tend to keep in the background on social occasions? Y=N

34) Does it worry you if you know there are mistakes in your work? Y=N

35) Have you ever said anything bad or nasty about someone? Y=N

36) Would you call yourself tense or ‘highly-strung’? Y=N

37) Do you think people spend too much time safeguarding their futurewith savings and insurance? Y=N

38) Do you like mixing with people? Y=N

39) As a child, were you ever cheeky to your parents? Y=N

40) Do you worry too long after an embarrassing experience? Y=N

41) Do you try not to be rude to people? Y=N

42) Do you like plenty of bustle and excitement around you? Y=N

43) Have you ever cheated at a game? Y=N

118 X. L. Feng and A. Campbell

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013

44) Do you suffer from ‘nerves’? Y=N

45) Would you like other people to be afraid of you? Y=N

46) Have you ever taken advantage of someone? Y=N

47) Are you mostly quiet when you are with other people? Y=N

48) Do you often feel lonely? Y=N

49) Is it better to follow society’s rules than go your own way? Y=N

50) Do other people think of you as being very lively? Y=N

51) Do you always practice what you preach? Y=N

52) Are you often troubled about feelings of guilt? Y=N

53) Do you sometimes put off until tomorrow what you ought to do today?Y=N

54) Can you get a party going? Y=N

Understanding E-Mental Health Resources 119

Dow

nloa

ded

by [

Uni

vers

ity o

f Sy

dney

] at

18:

55 1

2 N

ovem

ber

2013