As a manic depressive, meeting new people face to face is not something Joy Ikelman can just do. 

"I happen to have a hefty dose of social phobias - extreme anxiety in social situations, near panic when going to someone's house," she said recently through an electronic mail interview. 

She was diagnosed with the illness in 1992 after asking her doctor for medication to help her get to sleep. "I felt like I was falling apart. In the olden days, this would have been called a nervous breakdown," said Ikelman, a Boulder scientist. 

When her psychiatrist suggested that she attend a local support group, her stranger anxiety kicked in. She panicked. She resisted. "It's difficult for me to be in group situations," she said. 

"On-line you are only known by what you write, and not how you look or how you come across in person."  -Joy Ikelman

 

The mental illness, also known as bipolar affective disorder, causes an otherwise healthy person to have periodic mood swings, from extreme liveliness to extreme lethargy. Nearly 1.3 million Americans will be diagnosed with the illness in their lifetimes, most of whom will be misconstrued as dark or overzealous people, according to the National Alliance for the Mentally Ill. 

But when Ikelman found other bipolars on the Internet - where people can develop entire relationships without so much as a handshake - she found a new way of dealing with her condition. 

"(On-line) you are only known by what you write, and not how you look or how you come across in person," she said. Recently she joined Walkers in Darkness, a virtual community of bipolar patients who communicate through what is called a "listserv" on the Internet. When she sends a message to the "listserv," it simulates a public conversation by copying and sending her words to the electronic mailboxes of hundreds of other members of the list around the world. 

Other users do the same, resulting in the same catalog of messages landing in everyone's mailbox. The number of messages sometimes can top 100 a day. 

Having the power not to participate qualms Ikelman's fears. 

"When you are in a physical support group, you are almost pressured to talk, just by virtue of being present. Not so on e-mail. Anonymity is very comforting. And one can leave as quietly as they joined, with no fanfare." 

No medical supervision 

What on-line patients are lacking, however, is medical supervision, some doctors say. 

While licensed psychologists and therapists may belong to the lists, they normally are there only to observe, said Constance Dalenberg, a psychologist and director of the Trauma Research Institute in San Diego who frequently monitors these medical "newsgroups." 

Still, the quiet presence of professionals may be the reason people like Ikelman go on-line in the first place, said Margaret Roath, a clinical social worker at the University of Colorado Health Sciences Center and president of the Colorado Mental Health Association. "There's something helpful in talking to other people who are going through the same thing you are. And if you add a therapist, you add a whole different focus," Roath said after looking through two days' worth of the Walkers' discussions. 

But some of those same Internet users are doing more than lending shoulders and passing out warm fuzzies. 

The majority of respondents to a Denver Post survey sent to several mental-health newsgroups said they considered what they were told on-line to be solid medical advice. As one respondent said, "I probably get more information on-line on any given topic than I would from a single (medical) or self-help book. With the number of battling voices, it's like getting multiple opinions." 

And messages like this one sent to Walkers are not uncommon: 

"I've been taking 20 mg/day of Prozac, but now I'm moving up to 40 mg/day ... Should I take all 40 mg at once, or take 20 mg twice a day?" 

Others go further, saying they disagree with their doctors' advice and are looking for alternatives. 

Roath said these discussions are fine as long as the doctor is kept in the loop. "If you have a good relationship with your patient and they get information that is contradictory to what you're saying, what you hope is that the patient will come back in and talk with you about it," she said. 

But that's not always the case, Dalenberg said. 

After responding publicly to several psychology students' electronic questions, the psychologist's mailbox was flooded with messages from patients and their friends, including these two: 

*"You sound very knowledgeable. My 4-year-old was molested by my husband. What should I do?" 

*"My girlfriend is an abuse victim and she cuts her wrists a lot. Last weekend she almost drove off a bridge. Any advice?" 

Dalenberg's first concern was that the patients mentioned were not under a doctor's care. 

But then she realized that people were trusting her not for her documented experience as a psychologist, but rather on her appearance of being knowledgeable. 

Qualifications not mentioned 

"Of the 39 messages I have received asking for help in the last three months, not one has asked me what my qualifications to answer the question might be," Dalenberg said. "If you will look at the newsgroups, you will note that most individuals do not post (messages) in a way that allows their credentials to be obvious." 

And when credentials were given, they were ambiguous. 

"The new "netter' might not be aware that Dr. Whoever, a frequent poster to the psychology lists, is actually a doctorate in chemical engineering or computer science," Dalenberg cautioned. 

Dalenberg holds strict boundaries on-line. "They are not going to get therapy from me over Internet." 

But as a doctor, she said she has a moral obligation not to leave them alone. 

"Some of them are hurting very badly. I have a sense that they have met one of us traditional types and we have failed them somehow, and so they are reaching out to the world and are looking for someone who has had a successful solution," she said. 

"At times the problems are so serious that the people who are posting (messages) are afraid that if they talk to a professional, they would be hospitalized or involuntarily be given help ... 

"They are afraid of our response." 

Reprinted by permission of The Denver Post