To the Editor: The recent MJA supplement provides an excellent summary of internet interventions for a range of psychiatric conditions, including anxiety, depression and substance misuse.1 However, in highlighting the positive uses of the internet, it is important to remember other aspects of online engagement that can have a negative impact on patients’ mental health. It is useful to ask patients specifically about their internet activities, as they will not necessarily volunteer this information.

For example, people can spend a large amount of time accessing pornography online. Negative effects of this may include the impact on existing real-world relationships, the cost, and the risks associated with participation in illegal activities. Some patients may go further, arranging to meet people they have encountered on the internet in person, which entails a risk of physical or sexual assault.

The internet provides an opportunity for discreet gambling and, as with other forms of gambling, the effects can be destructive. Excessive participation in online games such as World of Warcraft, to the extent that people spend virtually all their waking hours engrossed in playing games, can also be a problem.

Bullying and socially destructive behaviour occurring on widely used social networking sites such as Facebook can cause considerable distress to the victim. Such sites can be used to deliver unwelcome information (eg, ending a relationship by changing one’s Facebook status to “single” and “de-friending” the partner). Privacy can also be an issue, and Facebook provides much information to potential stalkers if users fail to adequately protect their data. Some medical practitioners have allowed patients to become their “friends” on Facebook, which can involve inappropriate access to the doctor’s personal life and a risk of blurring professional boundaries.2

Finally, the internet is increasingly being incorporated into delusions expressed by people with psychotic disorders.3 For example, patients with schizophrenia may have paranoid beliefs that derogatory material about them is being distributed via the internet.

Enquiring about patients’ internet activities is therefore a useful addition to the standard mental health assessment.