Table 5.

Limitations of seeking help online by study.

Author (year)	Findings related to limitations of online help-seeking
Bell et al (2018) [24]	The risk of triggering or reinforcing suicidal thoughts or behaviors. Unmoderated communities are risky as the fail-safe to remove risky content is not there.
Best et al (2016) [9]	Lack of understanding of indicators of quality. Lack of control of personal information once it is online. Lack of confidentiality when disclosing within your own social network. Lack of help-seekers’ health literacy. Formal online resources are limited and need to be known to be accessed.
Birnbaum et al (2017) [47]	The online environment can be misleading and stigmatizing that reinforces pre-existing misconceptions about mental health and psychiatric treatment options, which may contribute to treatment avoidance.
Burns et al (2016) [13]	There is still an overall orientation to not seek help, and barriers remain to all forms of help. This has concerning implications as it suggests that simply providing help through different means will not increase the likelihood that young people facing these barriers will actually use these new avenues of help.
Collin et al (2011) [12]	Despite overall increased mental health literacy and intentions to seek help, ReachOut.com visitors remain reluctant to seek help from traditional and face-to-face sources.
Feng and Campbell (2011) [27]	Young people are unaware of where to search for mental health concerns.
Frost et al (2016) [28]	It is unclear whether online help-seeking was acting to replace offline help-seeking for these young people or whether the internet facilitates help-seeking in young people who otherwise would not disclose their self-injury to anyone. Similarly, it is unclear whether the failure of these young people to seek help offline may reflect a lack of linking to offline support in current forms of online support for self-injury. Young people in the current sample went beyond discussion of the positive aspects of online communities and online culture, expressing concerns about triggering content, unmoderated discussions, and the glorification of self-injury.
Haner and Pepler (2016) [40]	The possibility exists that the online counsellors can misinterpret neutral or positive typed communication with the presence of a vocal cue to suggest warmth of tone.
Horgan and Sweeney (2010) [30]	A number of participants also reported that they believed it would be unreliable (15.1%), untrustworthy (5%), it lacks privacy (2.5%), is too impersonal (7.5%), and that insufficient support would be found (3.9%). A number of participants were concerned with the reliability of the information, highlighting that young people may be experiencing difficulty in determining the quality of information online.
Kauer et al (2017) [39]	Lack of trust in the accuracy of the information available on the internet was also a general concern for both the Link and comparison arms.
Mar et al (2014) [43]	Two participants spoke of the importance of advertising the existence of online support offline, explaining that they felt it was not intuitive to look for help online. Participants’ concerns over privacy generally linked back to the stigma of having friends or family find out about their mental health concern. Providers of e-mental health services for youth must appropriately address high suicide risk while maintaining a youth’s privacy, which may need to be breached in emergency circumstances.
Mars et al (2015) [36]	Young people have difficulties in classifying sites as either helpful or harmful, as some offer concurrent suicide-promoting and help-promoting content.
Rickwood et al (2015) [41]	Greater self-reliance online, with a slightly stronger peer influence, may be cause for concern, as young people and their friends may not be the best guides to appropriate mental health care.
Ruppel and McKinley (2015) [31]	Limited mental health literacy and limited knowledge about which resources are available.