Earlier this year, a darling of social media announced that she was quitting Facebook because she believed it was “a public health threat.”[1] Even though Rep Alexandria Ocasio-Cortez (D, New York) had relied extensively on social media to get elected, she more recently concluded that it contributes to “increased isolation, depression, anxiety, addiction, [and] escapism.”
She’s not alone. Last year, the American Academy of Pediatrics (AAP) published updated guidelines endorsing universal screening for depression in children aged 12 years or older, and Colleen Kraft, MD, past president of the AAP, told Medscape in an interview that she believed social media plays a role in the increased rate of suicide among adolescent girls. In the United Kingdom, government ministers are considering placing restrictions on social media to protect children and adolescents.[2]
Mental Health in Teens Declining
The emergence of social media has paralleled a decline in mental health globally, with the World Health Organization now listing depression as the leading cause of ill health and disability.[3] A recent high-profile study[4]showed precipitous spikes in mood disorders and suicides over the same period among adolescents and young adults.
Although two trends can occur independently, researchers have been asking for years whether they might be related, and recently large-scale epidemiologic studies have begun piecing together the initial clues to how social media might be affecting young persons.
It’s a question that the Center for Research on Media, Technology, and Health at the University of Pittsburgh is devoted to answering, says Brian A. Primack, MD, PhD. The center is “nondenominational,” he says, in that they’re not making a case for or against social media’s influence on health, but instead simply following the data.
In a 2018 analysis,[5] Primack and colleagues studied 1730 young adults (aged 19-32 years) who were separated into five groups by amount of social media use, ranging from those who abstained entirely to heavy users. The researchers then analyzed users’ symptoms of depression and anxiety.
They expected to discover a trend resembling a U-shaped curve, with higher rates of mental health issues associated with abstainers (because they were lacking opportunities for interaction) and high-volume users (because they were missing out on real-world relationships), with the middle groups having the lowest psychological burden.
Instead, what they saw was a straight line: The more the participants engaged in social media, the higher their risk for depression and anxiety.
“We were almost hoping for that U-shaped curve, because then you can recommend an optimal amount to people,” Primack said. “Unfortunately, the lowest risk was with the lowest amount or none.” He and colleagues have uncovered similar associations between increased social media use and social isolation,[6] issues related to eating,[7] and sleep problems.[8]
These results are in line with another recent analysis of 220,000 adolescents from two separate countries.[9] The study grouped social media with other digital media, such as video games and smartphone use, and found that high-volume users (> 5 hours/day) were 48%-171% more likely to report unhappiness, depression, or suicidal behavior than low-volume users (< 1 hour/day).
Looking Beneath the Trends
Although this growing body of evidence may seem shocking, there are difficulties in establishing true causality, some researchers warn. With nearly 3.5 billion people actively using this technology, the variables to be considered are innumerable.
“There are a lot more nuances and contributing factors that that argument doesn’t necessarily take into account,” says Ellen Selkie, MD, MPH, assistant professor of adolescent medicine at the University of Michigan in Ann Arbor.
But according to Primack, multiple theories may explain the link between social media use and depression, anxiety, and loneliness. Online socialization is possibly displacing in-person interactions, which are known to be psychologically protective. The association could also be self-selecting, in that those who are already have mental health issues may be turning to social media to ameliorate those conditions. It could also be that adolescents and young adults—who are already inclined to compare themselves with their peers—are having a difficult time separating fact from self-promotion on these platforms.
“Especially if someone is in a more vulnerable state, they move into the social media milieu and get the impression that everybody else is having a better, happier, more productive life than they are,” Primack says. “It’s very easy for people to feel worse in comparison.”
Some researchers believe it may be more instructive to consider how these groups are using these platforms, rather than how often.
“Two people might both use 2 hours of social media per day, but person A might just be looking at pictures of babies and puppies and clicking ‘like,’ whereas person B might be having angry interactions about politics, religion, and other hot-button topics,” says Primack. “Obviously, the association of that same 2-hour time frame might be very different for them.”
Primack and colleagues’ recent work indicates that passive use of social media is correlated with higher rates of depression than is active use (eg, creating your own content, directly connecting with friends).[10] They also found a linear relationship with the number of platforms used, with risk for depression and anxiety being greatest in those using a higher number of platforms (seven to 11) compared with the lowest (zero to two), even after controlling for total time devoted to social media use.[11]
Conversely, plenty of data suggest that social media can be a salve for many. Evidence has shown considerable benefit when social support networks grow to help such groups as disabled persons or those with mental illnesses, and that social media can enhance self-esteem and improve overall health by promoting smoking cessation and better eating habits.[12]
Yet communal experience can also foster shared trauma. Selkie’s research has focused heavily on cyberbullying and the ways in which it confers negative mental health outcomes on both victims and perpetrators.[13,14,15,16] She noted that simply observing cyberbullying secondhand can have demonstrable psychological effects. It’s something she has seen play out in her work with transgender youth, who must navigate their own negative interactions in life while also experiencing the secondary consequences of reading damaging sentiments directed at their peers.
“Teens are developmentally at a stage where they are creating their own identity and looking to peers and other people like them for guidance on what that identity is,” Selkie says. “Having a threat to that identity can be very powerful in terms of their mental health.”
The Pushback
To the counselors at reSTART, a rehabilitation facility for teenagers and adults whose lives have been destabilized by their use of digital media, there is no question of whether a correlation exists.
“That’s what we’ve seen for the past 10 years,” says Johnny Tock, MA, LMHCA, director of admissions and business development at reSTART. “Their identity is really wrapped up in their tech use. Who they are, their social circles, their feelings of self-worth—they’re all connected to that,” he says, adding that their symptoms mirror those of drug and alcohol addiction, and as such require a genuine detox period generally lasting 1-2 months.
“In a lot of ways, we’re rewiring the brain and trying to get them reconnected to life, to people, and to the importance of relationships and connections.”
That entails living in treatment centers that could have existed before the Internet. There are no screens, but instead highly scheduled days filled with assigned tasks, activities in nature, physical fitness, healthy eating, and open therapy sessions. But because living in the 21st century and avoiding digital media is all but impossible, they eventually have to learn how to use their phones, computers, and other elements in a productive, healthy way, via a transitional program that can last 4-9 months.
The Washington-based reSTART operates in the backyard of tech giants, such as Microsoft and Amazon, and Tock says that there is a growing belief, at least among the older members of this community, that digital technology is putting youth at risk.
That fits with anecdotal evidence popping up in the lay press in recent years. In October of last year, the New York Times published an article detailing the efforts of Silicon Valley titans and workers alike to keep their children away from digital technology, with one former Facebook employee memorably stating, “I am convinced the devil lives in our phones and is wreaking havoc on our children.”
Watching for Red Flags
How can healthcare professionals spot signs of danger associated with social media use in their patients? According to Selkie, parental concern is usually the tip-off. She also suggests directly asking adolescents about their social media use; whether they’re struggling with depression or anxiety; how often they use these platforms; and whether they’ve ever felt unsafe while using them, which can lead to discussions about cyberbullying.
In general, she has found her patients to be receptive to her queries.
“Kids have a good sense of how social media might play into their own personal struggles,” she says. “By virtue of them knowing better than a lot of parents about how the technology works, they’re able to use that to their advantage.”
She said they often express relief when she recommends such strategies as charging their phones in another room to ensure they’re getting adequate sleep, because it builds upon instincts that they already have.
Yet even the most well-intentioned parents or clinicians can find themselves facing the unreceptive glare of a teenager who is being told that something that dominates nearly all facets of their social life is potentially harmful to them. Selkie says this is why it’s particularly important to move away from the narrative that has been routinely propagated about social media: that teenagers are to blame for their own overreliance on it.
“If we do that, we’re in danger of blaming teens for depression and anxiety without taking into account a lot of other things that might be happening. Blaming social media leads to the temptation to take away the social media. I think that is often counterproductive because of the positive things that teens can experience on those platforms. We need to be more balanced about what we demonize.”
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