Analysis of search queries as a tool for comparative assessment of the need for psychotherapeutic help

Chernenko Anton Mironovich PhD in Physics and Mathematics Head of the Sector, Space Research Institute of the Russian Academy of Sciences 117997, Russia, g. Moscow, ul. Profsoyuznaya, 84/32, of. 202 anton.chernenko@gmail.com Agarkov Vsevolod Aleksandrovich PhD in Psychology Researcher, Institute of Psychology of the Russian Academy of Sciences 129366, Russia, g. Moscow, ul. Yaroslavskaya, 13s1, of. 108 agargor@yandex.ru

Bronfman Svetlana Aronovna PhD in Medicine Senior Researcher, - Sechenov University 119991, Russia, g. Moscow, ul. Trubetskaya, 8s2, of. 305 chernenko.mtu@gmail.com

Funding: The research was carried out with the financial support of the Russian Foundation for Basic Research (RFBR) within the framework of scientific project No. 18-013-00999

Conflict of interest: the authors declare that there is no conflict of interest

Received: 10.11.2020

Introduction

When studying the prevalence of various mental disorders (and or psychological distress), in particular, depressive and anxiety states, the researcher faces a serious problem: what is the frequency of occurrence of such conditions in a particular population group in a given period of time. This is due both to the difference in diagnostic approaches and classification of a particular mental (psychological) suffering (as is known, there is a difference in approaches to diagnosis between psychiatric schools), and to serious disagreements in the ideas of psychopathology with a very common psychodynamic approach today, as well as the lack of certainty of certain concepts ^{[4,2, 12]}.

In addition, the problem of identifying those who need psychiatric and or psychotherapeutic help continues to be very relevant and significantly complicates the already confusing epidemiological picture. It is known that the number of really detectable patients depends on the tolerance of the population to what can be called "trust in psychological and psychiatric care", which in our country, due to well–known reasons and cultural characteristics, is quite low ^[1], Detectability depends on the socio–demographic structure of the population, as well as on the number and the possibilities of institutions and private practitioners providing psychiatric (psychotherapeutic, psychological) assistance in this area ^{[12, 9]}. The latter, according to Rothstein et al. ^[12], is especially important, and the most significant, from our point of view, is the adequacy of organizational forms of assistance to the socio-cultural characteristics of the population. At the same time, the emergence of new organizational forms (private psychiatric clinics, psychotherapeutic care offices in city polyclinics, the organization of a Center for free psychological assistance to the population, private psychological centers, a rapid increase in the number of private practicing psychotherapists, as well as psychologists providing counseling and psychological - psychotherapeutic support and the development of online counseling) leads to the identification of new patients. Thus, there are a large number of those who need psychiatric (psychotherapeutic) help, but have no intention of applying for it to existing state institutions providing specialized medical care (neuropsychiatric dispensaries and outpatient departments of psychiatric hospitals).

It is known that the analysis of the dynamics of the spread of some mental disorders over the past 50-70 years shows their steady and rather significant increase, however, the increase in morbidity has a pronounced correlation with the increase in the number of psychiatrists and other professionals in the field of mental health ^{[2, 12, 13]}. Thus, V.G. Rothstein, introducing the idea of a "class of depressions", explains such a surge in the prevalence of depressive disorders by identifying and including depressive, anxious and anxiety–depressive states in this concept ^[11], which are often found when patients apply for completely different reasons or are found not at all at a medical appointment, but either in the process of epidemiological study of the population, or when seeking help in psychological centers, and often to private practitioners on condition of anonymity ^[12,9,11]. Veltischev, relying on the previously introduced concepts of "depression class" and epidemiological studies of the prevalence of depression in the population, introduces the concept of "depressive spectrum", following Vertogradova, taking more than half of the observations of depression to the transitional, subclinical level, with minimal severity of symptoms, and at least 40% of observations to the neurotic level with the appearance of some objective signs of maladaptation ^[4,7]. According to the observations of Vertogradova, the frequency of occurrence of anxiety (57.6%) and depressive (26%) states, detected during an epidemiological study of employees of one of the enterprises in Moscow, can be explained by the identification of a large number of patients with subclinical, "prenosological" forms, which usually remain out of sight when studying the prevalence of affective disorders by seeking psychiatric help to specialized institutions ^[7]. An analysis of the reasons for non–appeals of potential patients by mental health professionals revealed both an insufficient level of emotional and bodily awareness in some of those suffering from affective disorders, and a lack of knowledge about where to turn and what psychotherapeutic help is. However, the overwhelming majority of the surveyed admitted that they do not trust official psychiatry and avoid contact with psychiatrists (and, I think, with any specialists in mental suffering, including psychotherapists and psychologists), although there were also those who received psychotherapeutic help, usually from private practitioners.

In recent decades, due to the rapid development of out-of-hospital or, better to say, "out-of-psychiatric" (referring, of course, to the traditional structure of medical institutions providing psychiatric care - a neuropsychiatric dispensary and psychiatric hospital) care, in Moscow and other megacities, potential consumers of psychotherapeutic services have the opportunity to receive it for free (for example, in Moscow Psychological Assistance Service to the population or with psychotherapists in state or departmental polyclinics), as well as in commercial medical or psychological centers. However, according to opinion polls, psychologists and psychotherapists are trusted by no more than 13% of economically active Russians (15% of women and 12% of men), and no more than 3% of respondents have experience of contacting a specialist, and 9% of respondents are sure that a psychologist cannot help in any situations ^[8]. As we pointed out earlier ^[1], the decline in confidence in psychotherapy in our country is largely due to the fear of disapproval of applying for psychological (psychotherapeutic) help by a reference group (friends, colleagues, family members, etc.), emphasizing the fact that receiving psychotherapeutic help in the representation of its potential consumers is closely related to insecurity and shame.

Noteworthy is the noticeable predominance among young people under 24 who are ready to trust specialists in case of a difficult psychological situation or emotional discomfort. From our point of view, this may indicate a fundamental change in the social environment, changes in the attitude of the reference group to psychotherapy and the formation of loyalty to psychological assistance. Our hypothesis is that the formation of reference groups in the last few years has undergone significant changes caused by the avalanche growth of Internet technologies (social networks, interest groups, applications for communication and dating, as well as special resources for communicating with professionals in the provision of psychotherapeutic (psychological) assistance); the reference group of young people today – this is, to a large extent, an online community of equal, but at the same time different, often unfamiliar in everyday life, but openly sympathetic and striving for each other people who reveal themselves without fear of being recognized, boldly and generously giving ideas, knowledge and experience.            

The above may also indicate serious changes in the individual's search for psychotherapeutic help. Internet technologies have not only changed the reference groups of the vast majority of residents of megacities (especially students, youth and economically active middle-aged people), but also created opportunities to search for medical and psychological help, including by relying on the experience and recommendations of the reference group ("word of mouth"), however, most often, the initial stage of the search is the formulation of the search query. It seems that in the realities of the last decade, it is the analysis of online activity in the direction of finding psychotherapeutic help that can give researchers the clearest picture of the need of various social groups for psychological (psychiatric, psychotherapeutic) help. This parameter can be called "true appeal", in contrast to the appeal to psychiatric medical institutions, the analysis of which is traditionally resorted to to assess the prevalence of affective, anxiety and other mental suffering ^[9,12]. Thus, we can talk about fundamental changes in the medical behavior of people who need the help of psychotherapists (psychologists). 10-15 years ago, most of them, due to the insufficient level of trust in psychotherapy and alertness towards psychiatry (closely related in the mass consciousness to psychotherapy and psychological help) caused by the social and ideological realities of the recent past, as well as a lack of information ^[1], would hardly have been able to use psychotherapeutic help. Perhaps anonymity plays an important role in the preference of Internet technologies for finding psychological help, which, as a rule, cannot be provided by state medical institutions and psychological assistance centers. Thus, according to the Moscow City News Agency, with reference to the director of the Moscow Psychological Assistance Service for the period from January to November 2018, 58 thousand people applied for psychological help, but it seems that the appeal to the Centers for free psychological Assistance is significantly lower than the need, which to a large extent may be it is connected with the impossibility of anonymous reception. Paradoxically, the risks of online search (for example, running into a charlatan or simply an insufficiently qualified psychotherapist or psychologist) are significantly inferior to the motivation to remain incognito for the specialist providing assistance.

It is necessary to note some important features of the search for psychotherapeutic help. First of all, as L. Zemnukhova rightly points out ^[10], psychotherapeutic help is a case of sensitive experience, in particular, because this experience is emotionally and ethically filled and requires additional reflection ^[10,15]. Psychotherapeutic experience is born gradually, going through such stages as preparation, self-help, primary experience, long-term experience ^[16]. The search for psychotherapeutic help is not only a sensitive, but also a reflexive experience, in which scrupulous work takes place to build a narrative of one's own identity ^[14] of recognizing and naming one's feelings and states; this experience involves the problem of transition from the ordinary language of mental suffering to the language of concepts and definitions, because the thesaurus of everyday life is far from professional jargon, even in its most "gentle" version. Thus, we can talk about the "thesaurus of untranslatability", the creation of a language of mutual understanding between medical and psychological science (psychotherapy and psychology, in particular) and society ^[3]. The search for psychotherapeutic help is always an attempt at self–disclosure, therefore it cannot but be associated with ideas about what is socially approved and accepted by society, primarily by the reference group.

According to L.Zemnukhova, three types of strategies can be distinguished in the search for mental health professionals: technological, physical and social ^[10]. The physical one is focused on attending thematic events and personal acquaintance with the specialists who conduct them (lectures, trainings, seminars, conferences, etc.). The most reliable, according to the author, is the social type of search, which is based on the recommendations of acquaintances ("word of mouth"), although it often fails. In addition, the request itself among the circle of offline acquaintances requires self-disclosure, which often becomes an obstacle to the use of traditional "word of mouth". In such a situation, the principle of "word of mouth" begins to work through an expanded reference group, as well as the implementation of a technological type of search strategy using search engines. The technological type of search strategy, in addition, allows you to analyze search queries, which can be an important tool for assessing the needs for psychotherapeutic assistance, as well as the ideas about psychotherapy of those who carry out the search.   

The analysis of search queries related to a specific medical and/or psychological problem, the study of the dependence of their frequency on time, on geographical location is an important research tool, since the statistical characteristics obtained in such a study are independent of traditional statistics based on the analysis of patients' appeals to medical or psychological institutions.

The most famous study of this kind is the Google Flu project, the purpose of which was to monitor search queries allegedly associated with the appearance of early symptoms of influenza ^[17]. Despite the fact that the pilot project ended in failure, its results were analyzed by a number of researchers, and now it can be considered established that the analysis of search queries is a useful tool for epidemiological research.

There have also been studies of condition queries directly related to mental health, including their seasonal fluctuations ^[18]. On the other hand, requests for help, being much more diverse, less structured and vaguely related to certain conditions, did not fall into the field of view of researchers.

The purpose of the study:

to conduct a pilot analysis of the search queries "condition" and "help" to assess the needs of users for the services of mental health professionals.

Materials and methods

In this study, two types of search queries were studied: "status" queries and "help" queries. Status queries are queries concerning the actual mental state of a person or his intended diagnosis, for example, "depression", "anxiety", "panic attack", etc. To obtain data on the frequency characteristics of queries, the capabilities of the Google Trends web application were used, which is based on Google search and shows how often a certain term or the word is searched in relation to the total volume of search queries in different regions. Requests for "help" were investigated based on the results of an anonymous questionnaire of those who applied for psychological help to the Moscow Psychological Assistance Service for the Population. To solve this research problem, a special questionnaire was developed aimed at identifying previous experience in seeking and receiving psychological help/psychotherapy. The questionnaire included a question about the wording of searches on the Internet in case you need psychological care / psychotherapy: "What are the queries to the search engines Yandex, or Google, You would have made if necessary to obtain psychological psychotherapy? (list 3-5 phrases for the query in descending order of frequency)?"

Research results

At the first stage, a study was conducted of the history of the most frequent "state" search queries and their correlation with each other, seasonality, and daily fluctuations.

To this end, the main queries were analyzed, presumably related to certain psychological "states". Below are the results obtained from the search queries "depression" and "anxiety" in the Google Trends web application.

Figure 1 shows graphs of the number of search queries for "states" - for the keywords "depression" and anxiety". Due to the significant statistical spread, seasonal variations are not clearly expressed, however, trends for increasing their number are clearly visible in the dynamics of both queries.

To identify seasonal variations of "state" queries, they were averaged over 5 years. The result is shown in Fig. 2.

It can be seen that the seasonal variations of the query "depression" qualitatively repeat seasonal fluctuations, which are one of the main characteristics of this disease: spring-autumn peaks of appeal with summer-winter recessions Attract attention and the greater severity of the autumn peak in the number of requests.

At the same time, the graph of the frequency of requests for the word "alarm" does not have such a pronounced cyclicity and does not show an upward trend in the second half of the year. The reliability of the peak at week 15 requires additional research.

The daily fluctuations in the number of "status" requests were also studied. Figure 3 shows the daily graphs of the queries "depression" and "anxiety", obtained by averaging data for one week in Moscow and St. Petersburg. The choice of these two cities was due to their location in the same time zone, which made it possible to avoid distortion of the results associated with the time difference.

Figure 4 shows a scattering diagram for the daily variations of the "state" queries, it is obvious that there is a fairly high correlation between them, r = 0.72.

Identification of typical search queries for the need for psychological assistance based on a questionnaire.

Unlike "condition" queries, for which the number of possible keywords is quite limited, queries related to the desire to receive psychological or medical help are extremely diverse. The system of Google Trends and a similar system Yandex.Word selection (a service for assessing user interest in specific topics) provides data on requests strictly in the form in which the request was provided at the login. Therefore, the first task was to select the most frequently used keywords by those wishing to receive help,

For this purpose, an anonymous survey was conducted of persons who applied for psychological help at the Center of the City Psychological Counseling Service. To solve this research problem, a special questionnaire was developed aimed at identifying previous experience in seeking and receiving psychological help/psychotherapy. The questionnaire included a question about the wording of searches on the Internet when searching psychological care/psychotherapy: "What are the queries to the search engines Yandex, or Google, You would have made if necessary to obtain psychological/psychotherapeutic help? (list 3-5 phrases for the query in descending order of frequency)?"

According to the results of the survey, the keywords that were found in the largest number of respondents were selected. Such keywords turned out to be:

· help of a psychologist

· consultation of a psychologist

· psychological help

· consultation with a psychotherapist

· psychological assistance center

Despite the apparent semantic similarity between these queries, the correlation between them was not very high, as can be seen from the following table of correlation coefficients. Presumably, this is partly due to significant fluctuations in the number of requests.

Table 1. Correlations between search queries

The statistical data of requests for each of these keywords turned out to be significantly less informative than for "status" requests, therefore, for further analysis, the annual graphs of the number of "help" requests were immediately averaged over 5 years and summed up. The corresponding averaged graph is shown in Fig. 5.

Analysis of this graph shows that:

(1) There is a seasonal cyclicity similar to the query "depression" - with spring and autumn peaks

(2) Unlike the query "depression", there is a noticeable downward trend towards the end of the year,

To clarify the second observation, Figure 6 shows the ratio of the number of "help" requests to the number of "status" requests. From the analysis of the figure, it can be concluded that this ratio does not show seasonal cyclicity, but demonstrates a clear downward trend. Thus, it can be assumed that the interest in receiving help for people with symptoms of depression and/or anxiety monotonously decreases by the end of the year.

Conclusions:

Seasonal variations of the query "depression" qualitatively repeat seasonal fluctuations in the frequency of occurrence of the disease: spring-autumn peaks alternate with summer-winter declines, which may indicate the reliability of evaluating search queries as a tool for analyzing depressive and anxiety –depressive states. Variations of requests for "help" also have a similar cyclicity, which may indicate that the analysis of search queries for psychotherapeutic assistance is a fairly reliable tool for assessing the need for such assistance among the population. However, this statement is preliminary and requires further research and more reliable justifications.   

Figure 1. Dynamics of search queries for the keywords "depression" and "anxiety" for 5 years - from 2014 to 2018 inclusive

Figure 2. Seasonal variations in the number of "status" requests

Figure 3. Daily variations of status queries, total data for Moscow and St. Petersburg, averaged over a week

Figure 4. Correlation between "status" requests during the day

Figure 5. The average schedule of "help" requests as a function of the week number of the year

Figure 6. The ratio of the number of "help" requests to the total number of "depression" + "anxiety" requests