Acceptability of Internet
INFORMATION
TECHNOLOGY
Shih Ying Gun
Student, Faculty of Medicine, University of New South Wales,
Sydney, NSW, Australia.
Nickolai Titov
Senior Lecturer, Clinical Research Unit for Anxiety and Depression
(CRUfAD), School of Psychiatry, University of New South Wales
at St Vincent’s Hospital, Sydney, NSW, Australia.
Gavin Andrews
Professor, Clinical Research Unit for Anxiety and Depression
(CRUfAD), School of Psychiatry, University of New South Wales
at St Vincent’s Hospital, Sydney, NSW, Australia.
Correspondence: Dr Nickolai Titov, CRUfAD at St Vincent’s
Hospital, Level 4, O’Brien Centre, Corner Burton and Victoria Streets,
NSW 2010, Australia.
Email: nickt@unsw.edu.au
doi: 10.3109/10398562.2011.562295
© 2011 The Royal Australian and New Zealand College of Psychiatrists
treatment of anxiety and
depression
Shih Ying Gun, Nickolai Titov and Gavin Andrews
Objective: The Internet is increasingly used to deliver treatment programs
for common mental disorders. However, little is known about the acceptability
of online interventions. The present study used an online survey to explore
levels of acceptability of Internet-based treatment programs for anxiety and
depression.
Methods: Visitors to websites operated by the Clinical Research Unit
for Anxiety and Depression (CRUfAD), were invited to complete an online
questionnaire during 16 weeks in 2008.
Results: Of 1543 people who began the survey, 1104 (72%) Australian
health professionals and lay people completed it. Internet treatment programs
for people with mild or moderate symptoms were more acceptable than
programs for people with severe symptoms. There were no differences between
health professionals and non-health professionals in acceptability ratings. As
expected, previous users of Internet treatments reported significantly greater
acceptability and preference for Internet treatments than non-users.
Conclusions: Respondents rated Internet-based treatment programs as
acceptable, with higher ratings from previous users. In order to facilitate
implementation, program developers need to implement strategies for increasing
knowledge about the efficacy and effectiveness of such programs, and engage
therapists and consumers in establishing ethical and professional guidelines
for their safe and responsible use.
Key words: anxiety, attitudes, depression, Internet, survey.
T
he growing availability of fast and reliable Internet services has contri-
buted to the Internet becoming an important source of information
about health conditions, including anxiety and depression. In parallel,
an increasing number of researchers and clinicians have begun to develop
and evaluate the potential of treating such conditions via the Internet.1
Meta-analyses of Internet or computer-based treatment programs for anxi-
ety disorders and depression indicate that many are clinically efficacious or Australasian Psychiatry • Vol 19, No 3 • June 2011
effective,2,3 with the amount of clinician time required usually considerably
less than for face-to-face treatment even when similar outcomes are
obtained.4–6 This compelling evidence base is encouraging federal govern-
ments in several countries, including Australia, Holland, and England, to
fund trials or to begin implementing such programs as part of national
health services. However, while clinical and cost effectiveness are impor-
tant, the acceptability of such services is a third essential criterion likely to
affect implementation. Acceptability refers to the degree that patients, clini-
cians or others are comfortable or at ease with a service or are willing to
use it.7 Indicators of acceptability include take-up rates, completion rates,
and perceptions by different stakeholder groups.
Studies reporting the acceptability of Internet or computer-based treat-
ment programs have typically described mixed results. For example, the
259
 attitudes of mental health professionals in the United
Kingdom8 and Norway9 towards Internet or computer-
based treatment were positive or neutral, but few
reported experience with using them. In contrast, a
survey of mental health professionals in the United
States10 indicated that the majority of the more than
2000 respondents did not see themselves using the
Internet to provide therapy in the future, and only 2%
of the sample reported currently using the Internet to
provide treatment.
Systematic reviews indicate that people treated with
Internet and computer-based treatment programs report
high levels of acceptability, with drop-out rates compa-
rable to other forms of treatment, but lower take-up
rates.11,12 Experience also appears to be an important
mediating factor with at least one study reporting that
greater familiarity of Internet-based treatment by pro-
fessionals was associated with greater levels of accept-
ability,9 and initially poor attitudes towards a
computer-based treatment for depression by university
students were improved following a demonstration of
the program.13
Information about the attitude of Australians to the
use of the Internet is a research priority, given the
Federal government’s funding of several trials of treat-
ment programs. The present study sought to compare
attitudes of Australian health professionals and lay
people, and of previous users and non-users of such
services. Additional questions explored respondents’
likely future use of Internet treatments, their prefer-
ence for Internet or face-to-face treatments, whether
these varied by group, and whether acceptability var-
ied by the severity of symptoms that were to be treated.
A final aim was to identify perceived barriers to the
uptake of Internet-based treatment.
Because of limited data about the attitudes of the
public,12 no hypothesis was formulated about likely
differences between attitudes of health professionals
and lay people. However, it was expected that respon-
dents would express more positive attitudes towards
Internet-based treatment of mild or moderate symp-
toms than towards treatment of severe symptoms and
that respondents who reported previously participat-
ing in Internet treatments would report higher overall
acceptability and greater intention of using such ser-
Australasian Psychiatry • Vol 19, No 3 • June 2011
vices in the future.
METHOD
Survey development
The Internet-based survey was developed as an ‘open’
survey, using a convenience sampling method. Visitors
to websites hosting a link to the survey were invited to
participate.
The overall questionnaire comprised four sections.
Section 1 enquired about demographics, including ask-
ing respondents to identify a stakeholder group (e.g.
260
consumer, general practitioner, etc), and experience
with and use of the Internet. Sections 2 and 3 asked
respondents to rate on a 5-point scale (1  definitely
not; 3  neutral; 5  definitely yes) whether they
thought it was a good idea to provide Internet-based
treatment for mild, moderate or severe symptoms of
anxiety and depression. Respondents were then asked
to rate if, overall, they thought it was a good idea to
provide treatment for anxiety and depression over the
Internet. Internet treatment was defined in the follow-
ing way: “Internet treatment websites are those that
directly provide treatment for anxiety or depression.
Treatment might involve completing a structured set
of lessons or modules online, and/or working with a
therapist online”.
The final section enquired about the respondent’s
own use of the Internet for treatment of anxiety or
depression and their likely future use for this purpose,
and about potential barriers to the use of Internet-
based treatment for anxiety and depression based on
questions asked by similar research.8,10 The questions
and functionality of the survey was pilot tested
on two occasions, and questions were subsequently
modified to improve comprehension. No formal
analyses of internal reliability or validity were
conducted.
This study was approved by the Human Research Ethics
Advisory Committees of the University of New South
Wales and St Vincent’s Hospital, NSW, Australia. All
participants completed an informed consent form
before beginning the survey.
Recruitment and survey administration
The survey was presented online via websites (www.
crufad.org, www.gpcare.org, and www.climateclinic.
tv) managed by the Clinical Research Unit for Anxiety
and Depression, and via the websites of the Australian
Psychological Society, e-news of the General Practice
Mental Health Standards Collaboration, and e-news
of the Royal Australian and New Zealand College of
Psychiatrists. No incentives were offered for participat-
ing, but respondents were invited to contact the inves-
tigator to request a copy of the final results. IP addresses
of participants’ computers were used to prevent users
from repeating the survey.
Response rates
Between 26 August 2008 and 15 December 2008 (16
weeks), a total of 1543 respondents started the survey,
defined as completing the informed consent procedure
(Figure 1). Responses were excluded if respondents did
not complete the last page of the survey, were not
Australian residents, or were under 18 years of age. The
responses from the 1104 (72%) remaining respondents
were included in the analyses comprising non-health
professionals (n  648) and health professionals
(n  456).
 1543 individuals began the survey between 26/08/2008 – 15/12/2008 (16 weeks)

• Did not complete survey (n = 247)

• Not Australian residents (n = 148)
• Under 18 years of age (n = 9)
• Provided inconsistent or exaggerated
responses (n = 35)

1104 individuals met all inclusion criteria and were included in the analyses in the following

Non-health professionals (n = 648) Health professionals (n = 456)

Figure 1: Survey flow chart.

Analysis (n  57) of respondents reported they had previously

Analyses of acceptability of Internet-based treatment of
mild, moderate, or severe symptoms of anxiety and
depression were conducted with the entire sample.
Analyses of overall acceptability and analyses of future
intentions to use such treatments were conducted after
dividing respondents into health professionals and lay
people, and then repeating analyses after dividing
respondents into those who reported previously par-
ticipating in Internet treatment and those who did not.
Dependent variables that failed to meet standards of
normal distribution were analyzed with non-parametric
tests, analysis was otherwise with ANOVAs. Data were
analyzed using PASW 18.0 for Windows.
RESULTS
Sample
The mean age of respondents was 33.03 years
(SD  13.32); 69% were female, and the entire sample
(n  1104) reported spending a mean of 18.29 hours
per week (SD  15.76) online. Forty-one percent
(n  456) identified themselves as health professionals
(or students training to become health professionals),
and 59% (n  648) identified as lay people. Five percent
participated in Internet treatment (‘previous users’),
while 95% (n  1047) did not (‘non-users’).
Differences in ratings based on severity of
symptoms
Friedman tests were used to explore differences in the
overall sample between ratings of acceptability of treat-
ment for mild, moderate and severe anxiety and depres-
sion (Table 1). These revealed differences in overall
ratings by severity for treatment of anxiety (χ2 (2,
n  1104)  899.46, P  0.001), and treatment of depres-
sion (χ2 (2, n  1104)  931.15, P  0.001). Post-hoc
Wilcoxon Signed Ranks tests (with Bonferonni adjusted
alpha levels) confirmed that the differences between mild
and moderate, and between moderate and severe were
significantly different for ratings of treatment of both
anxiety and depression (z  –18.35 to –9.79, P  0.001).
Acceptability of Internet-based treatment
by groups
A Mann-Whitney U-test exploring differences between
health professionals’ (median  3, mean  3.23, SD  1.24)
and lay people’s (median  4.0, mean  3.36, SD  1.27)
Australasian Psychiatry • Vol 19, No 3 • June 2011

Table 1: Mean (SD) ratings of acceptabilitya for using Internet-based treatment programs for people with
anxiety and depression (n ⴝ 1104)
Mild Moderate Severe Mild Moderate Severe
Levels anxiety anxiety anxiety depression depression depression
Health professionals (n  456) 3.89 (1.14) 3.24 (1.26) 2.80 (1.41) 3.85 (1.17) 3.12 (1.28) 2.45 (1.35)
Lay people (n  648) 3.89 (1.14) 3.42 (1.30) 2.94 (1.43) 3.73 (1.27) 3.33 (1.32) 2.82 (1.45)
Overall means (n  1104) 3.84 (1.18) 3.34 (1.28) 2.80 (1.41) 3.78 (1.23) 3.24 (1.31) 2.67 (1.42)
aRatings were made on a 5-point scale (1  definitely not; 3  neutral; 5  definitely yes).

261

Table 2: Preferences for treatment modality: Health
professionals versus lay people (n  1104)
Health Lay
Treatment Professionals People Total
Preferences (n ⴝ 456) (n ⴝ 648) (n ⴝ 1104)
Internet 3.9% 9.1% 7.0%
Face-to-face treatment 71.1% 58.0% 63.4%
No preference (both 25.0% 32.9% 29.6%
about the same)
overall rating of acceptability of using the Internet for
treatment of depression and anxiety was not significant
(U  157385.00, z  –1.90, p  0.06). A second Mann-
Whitney U-test revealed that previous users (median  4,
mean  3.89, SD  1.15) gave higher overall ratings of
acceptability than non-users (median  3.0, mean  3.27,
SD  1.26) (U  38237.00, z  3.68, p  0.001).
Future treatment-seeking
A chi-squared test revealed that significantly more lay
people (50.9%) than health professionals (37.7%)
reported that they would seek treatment via the Inter-
net (χ2  18.83, df  1, p  0.001). A second chi-squared
test revealed that previous users reported that they were
significantly more likely (80.7%) than non-users (43.6%)
to seek future treatment via the Internet (χ2  30.09,
df  1, p  0.001).
Preferences for treatment modality
Respondents were asked whether they would prefer
treatment via the Internet, face-to-face, or had no prefer-
ence (Tables 2, 3). Chi-squared tests revealed a significant
difference between health professionals and lay people
(χ2  22.97, df  2, p  0.001), and between previous
users and non-users (χ2  11.19, df  2, p  0.004).
Barriers to uptake of Internet-based treatment
programs
Barriers to increasing uptake of Internet-based treat-
ment programs endorsed by respondents are included
Australasian Psychiatry • Vol 19, No 3 • June 2011
in Table 4, divided into those endorsed by health pro-
fessionals and lay people. A comparison between previ-
ous users and non-users was not conducted because of
the limited sample size.
DISCUSSION
This survey explored the acceptability of Internet-based
programs for treatment of anxiety or depression in a
volunteer sample of Australians (n  1104). Analyses
examined acceptability ratings by the entire group, and
also with two sets of groups comprising health profes-
sionals (41%) versus lay people (59%) or those who had
previously participated in Internet treatment (5%) ver-
sus those who had not (95%).
As expected, Internet-based treatment was more accept-
able for mild and moderate than for severe conditions.
Mean ratings for mild and moderate symptoms for
both health professionals and lay people were above
the neutral rating point of 3/5, indicating accepta-
bility. However, mean ratings for severe anxiety and
depression for both groups indicated a preference
against treating such patients via the Internet. This
evaluation is consistent with the recommendation of
the UK-based National Institute for Clinical Excellence
(NICE) endorsing the use of computerized cognitive
behavioural therapy programs as appropriate for mild
to moderate anxiety and depression, but not for severe
conditions.14
No difference was found in the overall rating of accept-
ability of Internet-based treatment between health pro-
fessionals and lay people, although there was a trend
towards higher rating of acceptability by lay people. As
expected, respondents who reported experiencing
Internet-based treatment reported significantly higher
acceptability. This is consistent with research indicating
that acceptability is mediated by personal experiences
for both consumers13 and health professionals.9
A significantly greater proportion of lay people (51%)
than health professionals (38%) reported they would
use Internet-based treatments in the future. As pre-
dicted, a greater proportion of previous users of Internet
treatment (81%) than non-users (44%) also reported
that they would use such treatments, indicating that
the experience of Australian users appears to have been

positive.
Table 3: Preferences for treatment modality: Previous Similar results were observed with preferences for treat-
users versus non-users (n  1104) ment modality. Nine percent of lay people and 4% of
health professionals endorsed a clear preference for
Previous Internet-based treatment, while 58% and 71%, respec-
tively, endorsed a clear preference for face-to-face treat-
Treatment users Non-users Total
ment. While the majority of respondents prefer
Preferences (n  57) (n  1047) (n  1104)
face-to-face treatments, an additional 33% of lay people
Internet 17.5% 6.4% 7.0% and 25% of health professionals reported no clear pref-
Face-to-face treatment 50.9% 64.1% 63.4% erence for either modality, indicating that 42% of lay
No preference (both 31.6% 29.5% 29.6% people and 29% of health professionals rated Internet
treatments as potentially acceptable. Consistent with
about the same)
this, and as expected, a greater proportion of previous

262
 Table 4: Factors that would increase uptake of Internet-based treatment programs endorsed by respondents by
group and total

Health professionals (n ⴝ 456) Lay people (n ⴝ 648) Total (n ⴝ 1104)

n* (%) n (%) n (%)
I would like to learn more about the 352 (77%) 398 (61%) 750 (68%)
effectiveness of Internet-based treatments
I would like to learn more about the 275 (60%) 365 (56%) 640 (58%)
Internet-based treatments available
I would like to see established ethical/clinical 310 (68%) 329 (51%) 639 (58%)
guidelines towards Internet-based treatments
I would like to learn more about the legal 236 (52%) 193 (30%) 429 (39%)
issues involved/liability
I would like further training in how to use 136 (30%) 147 (23%) 283 (26%)
Internet-based treatment programs
No changes are required 34 (8%) 116 (18%) 150 (14%)
I would need a more reliable Internet service 26 (6%) 41 (6%) 67 (6%)
I would need to update my computer skills 18 (4%) 15 (2%) 33 (3%)
I would need more IT support 16 (4%) 14 (2%) 30 (3%)
n: number (percentage of group) endorsing item.

users (49%) endorsed either Internet or no preference
than non-users (36%).
When asked about factors that would increase the
uptake of Internet-based treatment, health profession-
als and lay people endorsed similar items with similar
rankings. High levels of endorsement were obtained
for the need for more information about: the effective-
ness of Internet-based treatment programs (endorsed
by 68% of respondents); the Internet-based treatments
available (58%); established ethical/clinical guidelines
(58%); legal issues involved/liability (39%); and train-
ing (26%). The magnitude of endorsement of these
issues is comparable to those reported in an earlier
UK-based survey of therapists’ attitudes towards com-
puterized cognitive behavioural therapy.8 These data
provide important suggestions about the information
and educational needs of professionals and lay people,
to assist them to make informed decisions about the
effectiveness and safety of Internet programs.
Implications
These findings revealed considerable support for the
acceptability of Internet-based treatment of mild and
moderate symptoms of anxiety and depression, but
opposition towards treatment programs of severe
symptoms. Moreover, although most respondents pre-
fer face-to-face treatments, more than one-third would
be willing to try Internet treatments in the future.
Respondents reported feeling uninformed about the
effectiveness, safety and professional issues around
the use of Internet treatments. This is not surprising
given that much of the published research is relatively
new and in scientific journals and that the use of these
programs is still mainly limited to clinical trials rather
than part of standard clinical practice.
Limitations
The self-selected nature of the sample is a limitation
of this study and it is likely that, having accessed the
survey from websites providing information about
Internet-based education and treatment programs,
respondents were biased towards positive evaluations.
The validity of respondents’ descriptions of group
status (health professional or lay person and previous
users and non-users) could not be independently
verified. A final limitation is that the total sample size
was modest, placing additional limits on the generaliz-
ability of results.
CONCLUSION
Respondents indicated higher levels of acceptability Australasian Psychiatry • Vol 19, No 3 • June 2011
towards Internet-based treatment of mild and moderate
anxiety and depression than severe conditions. Previ-
ous users reported significantly higher acceptability and
preferences for Internet treatment than non-users.
Importantly, although only a small proportion of over-
all users reported a clear preference for Internet treat-
ment (7%), an additional 30% reported they had no
preference of Internet or face-to-face treatment, indicat-
ing that more than one-third of respondents would be
prepared to try such programs.
The results of this survey indicate that the successful
implementation of Internet-based treatment programs
requires increased dissemination about results, the

263
 development of consensus clinical and ethical guide-
lines, and training programs for therapists.
ACKNOWLEDGEMENTS
The authors gratefully acknowledge the respondents for their involvement, and the Australian
Psychological Society, Royal Australian and New Zealand College of Psychiatrists, and
General Practice Mental Health Standards Collaboration for their assistance with recruit-
ment. This study was funded by departmental funds.
DISCLOSURE
The authors report no conflicts of interest. The authors alone are responsible for the content
and writing of the paper.
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