Most distressing is that many people browsing such sites may not have been properly diagnosed and may have simply assumed that they have an anxiety or panic disorder based on nothing more than having similar symptoms. Such people are not only at risk of neglecting their actual health problem, but might also be tempted to try treatments that are inappropriate to their actual condition. Unfortunately, the need for medical diagnostics appears to be the most neglected of the three educational concepts; despite the fact that it is perhaps the most important of these concepts.

For properly diagnosed anxiety/panic patients, it is distressing that nearly half the sites fail to acknowledge the values of CBT and medications. In failing to acknowledge these concepts, such sites can mislead or confuse patients who are seeking guidance. Without appropriate guidance, effective treatment is delayed; which not only prolongs suffering but may also allow the sufferer's condition to worsen.

On a brighter note, only one site was outright misleading (denying all three educational concepts) and more than a quarter of the sites addressed at least two of the educational concepts. Nonetheless, there is much room for improvement.

Another interesting note is that anxiety/panic patients are, by a small margin, the largest specific group producing web sites devoted to anxiety and panic disorder. This abundance of patient sites is possibly a reflection of past frustrations with the health care community. It is important to understand that such disorders were grossly misunderstood by most doctors until recent years. Coincidentally, in recent years the Internet came into popular use and many frustrated patients used this new medium to share experience, support and education. In many ways, Internet access has been a watershed for anxiety/panic patients who, because of agoraphobia or social phobia, had limited access to educational material and rarely interacted before.

At this time, a notable marketing fad is the repackaging of CBT under a variety of creative names and premises. Such packages are often promoted as unique methods of recovery (sometimes neglecting to mention CBT at all) and are often credited to supposed experts or enlightened patients. These programs are sold in the form of tapes, books or seminars; usually with exaggerated claims of effectiveness. Though such programs typically have some degree of educational value, they can also be harmful to patients as a distraction from more appropriate treatment and a burden to often stressed finances.

Direct marketing sites aside, the number of anxiety/panic sites with promotional content is roughly equal to the number of sites without promotional content. The most common form of promotion is banner ads. The products and services promoted by such banner ads vary greatly and are often unrelated to anxiety and panic disorders. Another form of promotion is web franchise; where one site forwards sale orders to another site in return for a small percentage of the profit. Unlike banner ads, there is a notable trend among the anxiety/panic franchise sites. Most of these franchise sites sell books regarding anxiety and panic disorders via prominent Internet book stores (most commonly Amazon.Com). Promotion of books can be very helpful to patients; however, many book franchise sites may have a significant bias in the books they promote. Patients are, perhaps, better served by accessing Internet book stores directly.

The lowest failure rate is found for sites advised by doctors of both psychology and medicine (16.7%). This is not surprising since such an advisory group is likely to have a well rounded perspective of both the medical and psychological issues of anxiety/panic. However, the failure rates for doctors of medicine (41.7%) or doctors of psychology (50.0%) is rather high. The main reason for these high rates is that many such sites promote awareness of clinical services without providing adequate educational material. In many such cases, doctors simply present their specialized perspective and neglect addressing the general issues of anxiety and panic disorder. In some cases, there is no attempt to educate at all. This high percentage of sites that are either lacking or highly biased in educational content can prove confusing to patients seeking appropriate treatment. Furthermore, this problem seems exacerbated by the high failure rate for the social worker group (71.4%) comprised of counselors and nurses.

The spiritual worker group, comprised of religious advisors and practitioners of alternative medicine, had a high failure rate (50.0%). However, this rate is probably not a reliable generalization since only two such web sites qualified for this study. Nonetheless, what is notable and troubling is that one of these sites actually denied all three of the educational concepts. This site suggested that medical diagnostics, psychotherapy and medications were all unnecessary in the treatment of panic attacks. Instead, love and acceptance was the recommended treatment strategy. As warm and friendly as this message may sound, it is also a misleading and potentially harmful message.

The patient group had the second highest failure rate (58.8%). This rate is, perhaps, not surprising since many patient sites regard personal experiences and do not attempt to provide general education of anxiety and panic disorders. However, of the sites that do address the educational concepts, it is interesting to note that the statistics of the patient sites is similar to the statistics of the medical doctor sites (equal numbers of sites for educational postures of 3, 2 and 1). Of course, the number of failed sites (educational posture = 0) is twice as high for patients compared to medical doctors, which is why medical doctor sites in general have a lower failure rate. Perhaps most interesting is that the failure rate for patient sites is lower than that for social workers; suggesting that educated patients are currently providing better education than some segments of the professional health care community.

With regard to direct marketing (2) we find the highest percentage of web sites (17.7%) corresponds to doctors of psychology. Similarly, we find high percentages for doctors of medicine (11.4%) and doctors of psychology and medicine (12.7%). Altogether, doctors who directly market their services on the web comprise roughly 42% of the anxiety/panic web sites. This is no surprise considering that roughly half the sites are advised by doctors in general, and that doctors usually offer information for making appointments.

Regarding sites that promote via banner ads and franchise (1), the highest percentage is associated with the unspecified persons group (8.9%), followed by the patient group (6.3%). Chances are that most of these sites are not making significant profits, but simply use ads and franchise to offset their Internet expenses.

Among the sites that neither sell nor promote (0), patients form the most significant group (11.4%). Patients produce such sites at their own expense for a variety of reasons. Some patients simply need to express what has been a very profound experience in their life. Others want to invite conversation with fellow sufferers. Many want to promote awareness, understanding and education. As mentioned earlier, such volunteerism among patients is probably motivated by the gross misunderstanding of anxiety and panic disorders in the recent past.

The notion of "commercial exploitation" may seem obvious at first. The term commonly conjures up an impression of marketers who knowingly prey on customer vulnerabilities. If we adopt this impression as a definition, we then have to compare this definition to the web sites in question. To begin, it is obvious that the people behind these sites are marketers because they are selling something. Less obvious is whether or not these marketers are preying on customer vulnerabilities. Well, in the world of anxiety and panic disorders, customers (i.e. patients) are often desperate for relief. Such desperation often compels patients to seek relief before gaining a practical knowledge of their disorders; disorders which are, at best, difficult to understand. Therefore, one of the greatest customer vulnerabilities is inadequate education. Since the web sites in question fail to address all three of the educational concepts considered, the case for commercial exploitation may seem to be proved. The problem, however, is that we can't determine if these marketers "knowingly prey" on customer vulnerabilities (at least not within the scope of this study).

Another way to view the commercial exploitation issue is from the perspective of web site developers. People who develop web sites are just as human as anyone else, and are just as capable of mistakes and oversights. In some cases, people develop web sites that directly market and can, through pure accident, forget the importance of including educational material. I know this for a fact because I, myself, made this exact same mistake when creating a site for my stepfather (who happens to be a psychotherapist). It wasn't until I conducted this study that I realized the gravity of my mistake (the site is included in these statistics and I plan to correct the site in the near future). Nonetheless, I doubt that all such sites are the result of innocent mistakes. Historically, people who suffer obscure disorders have always been targets of commercial exploitation.

Generally speaking, cases of "commercial exploitation" are difficult to determine. However, we can at least say that such web sites do create the potential for commercial exploitation, intentional or not. Such sites can confuse or mislead patients, delay appropriate diagnosis and treatment, worsen already stressed finances, prolong horrific suffering and subject patients to a variety of health risks. Such concerns are very important in regard to anxiety and panic disorders because such disorders have been, and sometimes still are, very misunderstood.

Finally, recognizing that such sites carry the potential for commercial exploitation, it is appropriate to ask who is creating such sites (see below).

Conclusions

• Web sites advised by BOTH medical doctors AND psychologists tend to offer the most complete educational content.

• Roughly half of the web sites do not address any of the educational issues considered in this study; including sites by health professionals.

• Nearly a third of the web sites present a combination of high marketing content and low educational content; which subjects patients to a significant risk of commercial exploitation.