Last time, I described the basics of compelling Web sites that we all would find useful. To recap, the sites should meet these specifications:

Information should be timely, accurate, complete, and unbiased.

• Information should be presented in an attractive style, for if it is not, it will be ignored.
• Information should be presented in a multimedia format, making use of audio and video where appropriate.
• Presented material should have bylines, resource lists, and references.

To ensure that these characteristics persisted within any established site would require that one of the primary concepts for respectable journalism be accepted within the online field: a firm division between advertising and editorial. We recognize, of course, that this division has been, at times, quite soft. Looking at television, for example, we know that in the late 50s and early 60s, the news staff of the “Today” show would serve Alpo to a handy dog in the midst of telling us the news. Music DJs on radio read most of the advertising copy well into the 70s.

How were listeners or viewers paying only partial attention supposed to know whether they were hearing news, entertainment, or paid advertising? This difficulty faded somewhat as we worked through the 80s and 90s, but more recently the hard line has again been eroded.
Sydney Bristow, a character on ABC’s “Alias,” needs to take an escape vehicle from the garage she is dashing through. “How about that truck” would suffice, but the actual line is, “What about the F-150?” It’s no surprise that Ford Motor Company is one of the sponsors of the show. I suppose it would bother me less if it meant watching one less commercial. News shows following “ER” occasionally fill time with stories dealing with a subject that had just been featured in the previous hour. Is it news? Or is it simply meant to keep viewers from switching to another channel?

So, finally, let me explain why I am discussing all this. Let’s look at examples of how information within an online addictive disease site might be biased:

A patient with alcoholism has just completed detoxification. He has a long history of depressed mood, suicide attempts, and alcohol use. He is now admitted to the halfway house and is seen independently by two separate clinical teams. The clinicians describe him as either:

a) The patient has had depressive symptoms with accompanying neurovegetative signs that have lasted for extended periods of time in a recurrent manner. Suicidal gestures and attempts have been recorded in the past medical record and appear to have been quite serious. Ongoing alcohol use has been concurrent with these depressive symptoms. The patient has gone through several detoxes and has been fired from two jobs as a result of his alcohol use. He is diagnosed with recurrent severe major depression and alcohol dependence. An antidepressant is recommended.

b) The patient has had concurrent alcohol use and depressive symptoms. Alcohol use began at a young age and there is no clear evidence of depressive disease prior to initial use. Although significant depressive symptoms are present, a primary psychiatric disorder other than alcohol dependence cannot be ruled in. The patient is therefore diagnosed with alcohol dependence, alcohol-induced depressive disorder, and has a rule-out of major depression. No medication is warranted in these circumstances.

There are two differences between approach (a) and approach (b). One is that of diagnosis and the other is that of treatment. Treatment team (a) believes that dual diagnoses are common and that as a result medication is often indicated quickly after detoxification has been completed. Treatment team (b) is more abstinence-based, does not rule in a dual diagnosis until a reasonable amount of time has passed or unless there is clear evidence for its existence, and believes no medication is indicated until a dual diagnosis has been ruled in. The two approaches are frequently used; neither is fundamentally wrong. Both represent a bias.

When Sydney Bristow takes the Ford® F-150 in favor of the Dodge® Ram, there’s nothing lost or gained in the storyline. And when Frank McGee fed Rover some Alpo, we knew it was a commercial. But when a Web site tells us that dual disorders are common, or that SSRIs can be used early in the treatment of an alcohol relapse, how do we know that the information isn’t presented because of underlying bias? The bias could be a result of poor journalism: the author has done his research but failed to note that the articles he or she refers to presented research findings funded by pharmaceutical companies. The bias could be a result of underlying support for the Web site itself. The bias could be simply the result of the author’s personal beliefs. In some contexts, that is clearly labeled. This is a column, for example, and we know that, within magazines, columns reflect the personal opinion of the author. Sometimes such authors are chosen because of a bias, sometimes because of the lack of one, but either way this becomes clear to regular readers. Within the typical unsigned Web site, the divisions among advertising, editorial, opinion, news, and entertainment are typically unclear. The relevance of this becomes critical as we look at another example:

A patient comes to the office after discontinuing heroin use on his own. He asks to be placed on buprenorphine. There is a tremendous amount of information online discussing this fairly new drug. There is much money to be made here, not only by the pharmaceutical company making the drug, but by organizations training doctors in its use, by journals accepting advertising, by educational groups accepting grants for trainings, and so forth. Suddenly, it’s difficult to find any discussion online regarding abstinence-based treatment of opioid dependence. Is this because such treatment is suddenly the wrong way to go? Or is there perhaps another reason?

I am not finished with this thread yet. This is turning into a three-part article, which gives you time to respond, perhaps changing my mind before I finish next time.

Stuart Gitlow, MD, MPH, is the author of Substance Use Disorders: A Practical Guide, from Lippincott Williams & Wilkins. He spoke at the Psychiatric Congress in Orlando in November 2003 on e-mail and the psychiatric patient.

This article is published in Counselor,The Magazine for Addiction Professionals, August 2004, v.5, n.4, pp. 50-51.

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