Internet Access for Patients on Psychiatric Units

Legal Background

During the latter half of the 20th century, legal actions at the state and federal levels in the United States promulgated several rights for psychiatric patients. In 1972, the landmark Alabama federal court case Wyatt v. Stickney⁵ established minimum constitutional standards for the treatment of patients with mental illness; the Wyatt standards, as they become known, included patients' rights to the “least restrictive conditions necessary to achieve the purposes of commitment” (Ref. 5, p 379), to send and receive sealed mail, to communicate by telephone, and to receive visitors. Under the Wyatt standards, a mental health professional may restrict these rights to mail, telephone or visitors, but only with a written order that must be periodically reviewed for renewal.

By 1977, at least a dozen states had passed legislation to protect patients' rights, with many states modeling these protections after the Wyatt standards.⁶ That same year, President Jimmy Carter formed the President's Commission on Mental Health, appointing First Lady Rosalynn Carter as honorary chairperson, to study mental health reform.⁷ The commission delivered its four-volume report to President Carter in 1978 and, citing the Wyatt standards, recommended the enactment of legislation providing a bill of rights for psychiatric patients.⁸

The recommendations of the President's Commission on Mental Health played a vital role in the congressional passage of the Mental Health Systems Act of 1980,⁹ legislation that proposed broad changes to mental health care in the U.S.⁷ During a signing ceremony at the Woodburn Center for Community Mental Health in Virginia, Secretary of Health and Human Services Patricia Harris remarked, “And too often our society has behaved as if the mentally ill do not have feelings, as if they do not have rights or talents or hopes for the future. The Mental Health Systems Act will not change these attitudes or those conditions overnight, but it is an essential beginning” (Ref. 10, p 2104).

In particular, the legislation included 42 U.S.C. 9501, a bill of rights for mental health patients. This section directed every state to “review and revise, if necessary, its laws to ensure that mental health patients receive the protection and services they require” (Ref. 11, p 7065). In keeping with the Wyatt standards, the bill of rights incorporated “the right, in the case of a person admitted on a residential or inpatient care basis, to converse with others privately, to have convenient and reasonable access to the telephone and mails, and to see visitors during regularly scheduled hours” (Ref. 11, p 7066) unless otherwise restricted by a mental health professional's written order as part of a treatment plan.

Though much of the Mental Health Systems Act was later repealed because of policy reversals under the Reagan administration, the bill of rights for mental health patients was left intact.⁷ Across the country, states have established laws along the lines of the Wyatt standards and 42 U.S.C. 9501, bolstering the protection of basic rights for patients in psychiatric facilities.^12,–,16 This proliferation of protections since the 1970s has prompted litigation by patients in numerous states; for example, in New Jersey,¹⁷ Kansas,¹⁸ Massachusetts,¹⁹ and California,²⁰ among other states, patients in psychiatric facilities have filed lawsuits citing grievances over access to telephones or to mail.

State legislatures have periodically revised these statutes over the last several decades, but the enumerated rights with regards to communication have remained similar; patients in inpatient psychiatric units are generally guaranteed rights to writing materials, uncensored mail, confidential telephone calls, and visitors, unless a mental health professional documents good cause for restricting these rights with a written order.

Internet Use by People With Mental Illness

Though patients on psychiatric units may have protected rights to mail, telephone access, and visitors, depending on their location, these rights have not necessarily kept up with the advances of the information age. Rising use of the Internet, including email, social media, and text messaging, has disrupted traditional modes of communication. For example, according to the U.S. Postal Service, its total mail volume fell from 203 billion items in 2008 to 150 billion in 2017: a 26 percent decline.²¹ The National Center for Health Statistics estimates that most Americans now live in households without a landline telephone.²²

Patients receiving psychiatric care are taking part in this digital revolution. Studies suggest most people with serious mental illness use the Internet, often at rates comparable with that of the general public.^23,–,25 In a 2014 online survey, 89 percent of individuals with schizophrenia reported using their personal computer for one or more hours per day, and 85 percent reported using mobile phones for one or more hours per day.²⁶ A 2016 meta-analysis found that half of patients with psychotic disorders in studies from the United States, United Kingdom, and Canada owned a smartphone, with ownership rates predicted to continue increasing.²⁷ Research has shown widespread use of social media among people with psychotic disorders and other forms of mental illness.^28,–,31

People with mental illness log online for reasons like anyone else, from communication to entertainment, but a great deal of research has focused on how these individuals use the Internet to look up health information. For many patients, the Internet has become a powerful source of information about health care. Studies from the United States³² and elsewhere^23,33,34 suggest that most patients with mental illness who use the Internet search for health information online. Some patients use the Internet to read about drug indications or side effects, whereas others want to learn more about psychiatric diagnoses, alternative treatments, coping strategies or support networks.²³

The Internet is also emerging as a platform for mental health interventions.³⁵ In the past 15 years, people have developed web-based approaches to helping patients with depression,³⁶ anxiety,³⁷ substance abuse,³⁸ schizophrenia,³⁹ and bipolar disorder,⁴⁰ among other conditions. Notably, mental health applications (apps) for mobile devices have proliferated; a study published in 2013 found more than 1,500 mobile health apps for depression alone.⁴¹ According to a report by the IMS Institute for Healthcare Informatics,⁴² the number of trials for mental and behavioral health apps submitted to ClinicalTrials.gov grew by 32 percent from 2013 to 2015.

Internet Use in Mental Health Facilities

Despite this growth in digital connectivity during recent decades, inpatient psychiatric units—especially wards where patients are involuntarily hospitalized—can still be austere, detached environments. Furniture and windows may be bolted down for safety reasons. The doors are often locked. The edge of every corner is designed to minimize the risk of suicide. Patients may have little contact with the outside world other than through staff, other patients, visitors, phone calls or mail.

The information gap between patients and providers can be considerable on psychiatric units. Inpatient psychiatric care is often a confusing experience for patients, with medical diagnoses, medications, and therapies that can require a high degree of health literacy combined with complex legal frameworks and often-ambiguous unit policies.^43,44 Though patients may receive information about their care from conversations with staff or leaflets, studies have repeatedly shown poor information sharing between patients and providers on inpatient psychiatric units.^44,–,47

A 2004 article by Dr. David Hellerstein in the New York Times addressed the clash between information technology and inpatient psychiatry: And the devices multiplied. Besides cellphones and laptops, we now had an influx of Palm Pilots and BlackBerries and pagers as well.And soon, perhaps predictably, problems arose. Some were practical. What if a device disappeared, or if one patient broke another's device? Nurses complained that they spent an inordinate amount of time untangling cords and baby-sitting delicate gizmos.Other issues were clinical. What if patients spent all their time on the phone and refused to go to therapy? What if substance abusers used their phones to “order in” their drugs of abuse (not a far-fetched idea in Manhattan)? Clearly, limits had to be set. On the other hand, we wanted some patients to talk on the phone: the ability to reach out to others might speed a patient's recovery from depression, or hasten the emergence from psychosis [Ref. 48, p F6].

Dr. Hellerstein went on to explain that the hospital restricted mobile phones due to concerns about privacy and tranquility on the unit. In concluding the article, he wrote, “My guess is that the battle has just begun” (Ref. 48, p F6).

Indeed, later that year, researchers published a study about information sharing in a United Kingdom psychiatric hospital.⁴⁵ Internet access had recently arrived on the wards and, in focus groups, hospital staff expressed concern that patients might encounter misleading mental health information online. Furthermore, the study authors learned that patients had already been found logging onto sites with pornographic and suicide-related content; at least one unit began chaperoning patients' Internet use.

Few comprehensive studies have examined Internet access on psychiatric units across the United States. In 2009, the Forensic Division of the National Association of State Mental Health Program Directors conducted a survey on Internet access for patients in forensic settings;⁴⁹ among responding representatives from 32 states, at least 30 indicated having policies that restricted patient access to the Internet in some way; most states allow limited Internet access for some patients in supervised settings (e.g., patients may earn privileges to go online with staff in a hospital library). Personal experience as a mental health provider and publicly available hospital policies suggest these kinds of restrictions are commonplace in nonforensic psychiatric settings as well.^50,–,54

Over the past several years, the matter of computer access in psychiatric facilities has prompted legal actions in several U.S. states.^55,–,60 In 2009, the U.S. District Court for the Central District of California decided Endsley v. Luna,⁵⁶ in which a patient who had been charged with murder and was found not guilty by reason of insanity had sued a state hospital for depriving him of access to a laptop computer. The patient argued that restricting his ownership of a laptop violated constitutional rights, while the hospital countered that allowing the patient to own a personal computer could lead to inappropriate use, such as online communication with prior victims or making plans to escape from the facility. The court granted summary judgment to the defendants, writing that “no clearly established law provides Plaintiff the right to possess a laptop computer.”

The U.S. District Court for the Northern District of California made a similar decision in Carter v. Foulk⁵⁹ in 2012, after a forensic psychiatric patient sued over the conditions at Napa State Hospital. Among other complaints, the patient argued that the hospital had deprived him of the right to own a personal computer, whereas the court cited the hospital's compliance with state regulations that restrict Internet access to patients hospitalized under forensic commitments. The court granted summary judgment to the defendants.

A 2014 decision⁶⁰ by the U.S. District Court for the District of South Dakota in favor of Black Hills Health Care Systems further highlights the controversial suffusion of electronic devices into mental health facilities. A patient voluntarily admitted himself to a drug and alcohol treatment program at a facility where patients were permitted access to computers. According to publicly available court documents, the patient had been advised that computer use would be monitored. When a computer audit allegedly found that the patient had accessed a naked photograph via an email account, he was irregularly discharged for viewing inappropriate materials. The patient filed suit against the hospital, citing an invasion of privacy, but the court granted summary judgment to the defendants.

Clinical Considerations

There are several negative consequences to consider when permitting Internet access to patients in inpatient psychiatric facilities. Some patients may encounter unreliable health information online,^34,61 potentially leading to poor medical decision-making or misunderstanding of the treatment process. Other patients may attempt to access inappropriate materials, such as prosuicide websites⁶² or delusion-related content,⁶³ that may be detrimental to the treatment plan.

The psychiatric effects of Internet access remain unclear from a clinical standpoint; for example, increased Internet use has been associated with depression, anxiety, and social problems in some studies,^64,–,67 though the causality between these links remains controversial.

Allowing patients who have acute psychiatric decompensation to communicate openly with the world could carry life-altering implications for them. What if a patient with psychosis sends threatening messages from his company e-mail account and loses his job? Should hospital staff allow a manic patient to continue posting delusional messages on public social media pages that might alarm family and friends?

Internet use by patients on psychiatric units also raises privacy concerns. While hospitalized, patients could go online and publish private information about other patients or staff. The prevalence of cameras in digital devices is particularly worrisome,⁴⁸ as patients could upload photos or video from confidential medical settings for the world to see.

Safety is another concern around psychiatric inpatients going online. From a practical standpoint, electronic devices can include cords, batteries, and small parts that may heighten risks of self-harm or assault; patients using these devices may need closer monitoring, increasing staffing needs and the costs of care. Further, psychiatric patients could use information online to harass providers, other patients, or former victims. In forensic inpatient settings, these safety risks are even more unsettling,⁶⁸ as many of these patients have histories of violence or harassment.

Still, fears of what might be should not dictate universal practices for inpatient psychiatry. Virtually anyone can misuse the Internet, including both patients and staff, but that does not justify sweeping restrictions against Internet use for everyone. As proposed by the original Wyatt standards, involuntarily hospitalized patients should be treated under the “least restrictive conditions necessary to achieve the purposes of commitment” (Ref. 5, p 379).

Just as Internet access on inpatient psychiatry may carry risks, allowing psychiatric inpatients to log online can also provide many clinical benefits. Through the Internet, patients in psychiatric care can attempt to maintain their lives outside the ward, from communicating with loved ones to addressing professional commitments. There are patients who may learn new information online about their mental health conditions, helping them make informed decisions about treatments or providing them with support networks. Patients can work with staff to coordinate discharge planning and follow-up care through online resources.

Some psychiatric facilities have embraced digital technology, such as introducing patient education tools through Internet portals.⁶⁹ Researchers are studying how computer-based education programs may be useful for patients in psychiatric units, for example by improving quality of life, decreasing functional disability, or providing alternatives to nursing.^70,71 Studies suggest that mobile devices can be useful for inpatient psychiatric care, such as tracking patients' moods over time.⁷² Psychiatric providers are also using advances in telepsychiatry to provide additional support to inpatients⁷³ and help facilitate discharge planning from mental health facilities.⁷⁴

Recommendations for Internet Policies in Inpatient Psychiatry

Whether patients on psychiatric units should retain Internet access is likely to remain controversial for some time. So far, U.S. courts have not established that Internet access is a constitutionally protected right for patients receiving inpatient psychiatric treatment. However, that does not provide grounds for blanket restrictions on Internet use by patients admitted to inpatient psychiatry. In the absence of more direct state or federal legislative mandates, medical institutions providing inpatient psychiatric care should carefully develop policies surrounding the use of the Internet by psychiatric inpatients.

In crafting these policies, psychiatric facilities should be mindful of the impact that policy shifts can have on patients and providers, as well as possible legal ramifications. As an example, Coalinga State Hospital in California allowed patients to own personal computers, until recurrent policy violations led the hospital to stop allowing purchases of computers and software for patients in 2007. The hospital eventually prohibited patients from owning electronic devices that could access the Internet in accordance with state regulations released in 2009. These restrictive electronic device policies led to a slew of legal challenges by patients that would take years to resolve.⁷⁵

Developing clear guidelines surrounding the use of electronic devices on inpatient psychiatric units can help mitigate confusion among both patients and providers. For instance, the Massachusetts Department of Mental Health has developed statewide policies regarding electronic devices in its facilities,⁷⁶ including procedures for clinical assessments on whether to allow a patient to use electronic devices. The department has also created electronic device agreement forms to be signed by not only the patient but also by members of the patient's treatment team. These policies are publicly available for review and download from the department's website.⁷⁷

Providers of inpatient psychiatric care may wish to tailor their Internet policies around specific patient populations. Voluntary psychiatric units may have very different patient characteristics compared with secure forensic hospitals. Similarly, adolescent psychiatric units will have different demands by patients concerning Internet access compared with geriatric units. Some states already regulate Internet use by certain patients in psychiatric facilities; California, for example, bars patients such as inmates of jail psychiatric units or sex offenders with mental disorders from accessing the Internet while in its Department of Mental Health facilities.⁷⁸

When allowing inpatients to access the Internet, psychiatric institutions may consider different approaches to supervision. One approach is to allow completely unsupervised Internet access for patients, though this comes with the risks described previously. Another approach is to regulate access to electronic devices, such as requiring that patients sign out devices from nursing stations or providing patients with access to password-protected hospital computers. A content-based approach may focus on preventing patients from accessing specific online materials, for example by installing website filters or having staff sit with patients during online browsing sessions.

Under circumstances where government statutes or institutional policies remain unclear in this regard, clinicians should consider using individualized assessments on the appropriateness of Internet use by patients on psychiatric units. Since not every patient is the same and requests for online access differ, mental health providers may wish to review patient requests on a case-by-case basis, particularly on involuntary units. Some patients may be appropriate for Internet use under varying degrees of supervision, whereas others may not be clinically stable enough for online access at all. Documenting reasons for allowing or restricting Internet access for individual patients can help clarify clinical decision-making for the treatment team, as well as for the patient, and may prove useful in the case of any legal actions that arise as a result of such decisions.