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CME / ABIM MOC / CE

Is Social Media a Risk Factor for Mental Health?

  • Authors: News Author: Pauline Anderson; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 10/25/2019
  • Valid for credit through: 10/25/2020
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  • Credits Available

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This article is intended for primary care physicians, pediatricians, psychiatrists, nurses, and other clinicians who treat and manage adolescents.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Assess the use of social media among US adolescents, and its potential effects on mental health
  • Evaluate the effects of social media use among adolescents on internalizing and externalizing mental health symptoms
  • Outline implications to the healthcare team


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News Author

  • Pauline Anderson

    Freelance writer, Medscape, LLC

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    Disclosure: Pauline Anderson has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD, FAAFP

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Genentech; GlaxoSmithKline
    Served as a speaker or a member of a speakers bureau for: Shire

Editor/CME Reviewer

  • Esther Nyarko, PharmD

    Associate Director, Accreditation and Compliance, Medscape, LLC

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    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

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  • Hazel Dennison, DNP, RN, FNP, CPHQ, CNE

    Associate Director, Accreditation and Compliance, Medscape, LLC

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    Disclosure: Hazel Dennison, DNP, RN, FNP, CPHQ, CNE, has disclosed no relevant financial relationships.

Medscape staff have disclosed that they have no relevant financial relationships


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CME / ABIM MOC / CE

Is Social Media a Risk Factor for Mental Health?

Authors: News Author: Pauline Anderson; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 10/25/2019

Valid for credit through: 10/25/2020

processing....

Clinical Context

If it seems that every US adolescent is linked to social media, that is because it is (nearly) true. The authors of the current study cite a 2018 poll that demonstrated that 97% of adolescent respondents reported using at least 1 of the 7 most popular social media platforms, with 95% reporting owning or having access to a smartphone.

Although social media can make communication efficient and create a virtual community for individuals who traditionally have been marginalized, there are concerns about the potential for social media to negatively affect the mental health of adolescents. Social media use may negatively affect sleep and expose adolescents to bullying. It may also expose adolescents to idealized social scenarios and body images, which in turn creates anxiety. One quarter of adolescents believe that social media has a mostly negative influence.

Rates of depression and suicidality have increased among US adolescents during the last 2 decades. The current study assesses how social media use affects internalizing (ie, depression, anxiety) and externalizing (ie, bullying, inattention) symptoms among adolescents.

Study Synopsis and Perspective

Adolescents who spend more than 3 hours a day on Facebook, Twitter, Snapchat, or other social media are at increased risk for depression, anxiety, or other internalizing problems, new research suggests.

The study did not find an association between social media use and externalizing problems such as physical aggression and impulsivity, but there was an association with such problems comorbid with internalizing symptoms.

"Social media has a lot of benefits; for example, it offers users an opportunity to connect with other people on lots of different topics and with people from all over the world. But there appear to be associated harms," lead authorKira E. Riehm, a PhD student in the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, told Medscape Medical News.

She indicated that balancing the 2 of these will be really important in the future.

The study was published online September 11 in JAMA Psychiatry.[1]

Easy Access

The authors note that depression is on the rise among American teenagers, and that rates of deaths by suicide and suicide attempts in this population have increased sharply during the last 2 decades.

These days, most adolescents have a smartphone, making it easy for them to access social media platforms at any time. But whereas some experts blame the rapid rise in social media use for increased depression rates, the authors point out that evidence for this in nationally representative samples is scarce.

To date, most studies looking at the effect of social media on mental health are cross-sectional, which presents significant limitations because of the possibility for reverse causation, said Riehm.

"It might be that instead of social media leading to more mental health problems, people with mental health problems are more likely to use social media."

Unlike previous studies, Riehm and colleagues used longitudinal data collected at multiple times, which helped determine that social media use came before mental health problems.

The team used a representative sample of 6595 US adolescents who participated in the Population Assessment of Tobacco and Health (PATH) study. Researchers gathered data from this survey in 1-year intervals, starting with wave 1 from September 12, 2013, to December 14, 2014, when study participants were aged 12 to 15 years.

In this wave, researchers collected data on demographic characteristics, body mass index, self-reported lifetime marijuana and alcohol use, and lifetime internalizing and externalizing problems. They adjusted for these potential confounders in their analyses.

During wave 2 (2014-2015), researchers asked respondents how much time they spent per day using social media sites such as Facebook, Google Plus, YouTube, MySpace, LinkedIn, Twitter, Tumblr, Instagram, Pinterest, and Snapchat.

About 16.8% of adolescents reported no social media use, 31.8% reported 30 minutes or less per day, 30.7% reported more than 30 minutes to 3 hours or less, 12.3% reported more than 3 hours to 6 hours or less, and 8.4% reported more than 6 hours.

Investigators assessed mental health problems during wave 3 (2015-2016), using the Global Appraisal of Individual Needs-Short Screener (GAIN-SS). From the responses, they created a single-outcome variable with 4 categories: no or low internalizing and externalizing problems (the reference group), internalizing problems alone, externalizing problems alone, and comorbid internalizing and externalizing problems.

"Internalizing" and "externalizing" problems are common childhood psychopathology classifications, said Riehm. Internalizing refers to inward distress such as anxiety, depression, withdrawal, and loneliness. Externalizing problems manifest in behaviors such as inattention, physical aggression, rule breaking, and impulsivity.

Some 9.1% of study subjects reported internalizing problems alone, 14.0% reported externalizing problems alone, 17.7% reported comorbid internalizing and externalizing problems, and the remaining 59.3% reported no or a low level of problems.

That more than 40% of survey respondents indicated some level of internalizing or externalizing problems "makes sense for this population," said Riehm.

She noted that the simple 4-item questionnaire "will pick up a lot of people who may have had some level of distress, but perhaps not a clinical level of distress that would be characterized as a mental health problem."

The unadjusted analysis showed that compared with adolescents who did not use social media, its use for more than 30 minutes per day was associated with greater risk of internalizing problems alone and comorbid internalizing and externalizing problems.

In the adjusted model, the associations for the 2 highest categories of social media use persisted for internalizing problems alone (>3 to ≤6 hours: relative risk ratio [RRR], 1.60 [95% confidence interval (CI), 1.11-2.31]; >6 hours: RRR, 1.78 [95% CI, 1.15-2.77]).

The associations for the 3 highest categories of social media use persisted for comorbid internalizing and externalizing problems (>30 minutes to ≤3 hours: RRR, 1.59 [95% CI, 1.23-2.05]; >3 to ≤6 hours: RRR, 2.01 [95% CI, 1.51-2.66]; >6 hours: RRR, 2.44 [95% CI, 1.73-3.43]).

Linear Relationship

According to the study, Riehm indicated it demonstrated a linear relationship in that the more time is spent on social media, the more likely to internalize problems.

In contrast, the association of social media use with externalizing problems alone was inconsistent in the unadjusted analyses, and not significant in the adjusted analysis.

This finding suggests that the association of social media use with comorbid problems is driven mostly by internalizing symptoms and the high comorbidity with externalizing problems, said the authors.

There did not appear to be any sex differences for internalizing, externalizing, or comorbid problems. This is in contrast to previous studies that found that the association between social media use and internalizing problems tends to be stronger in girls.

"The reason our study didn't pick up on that is that we were just measuring time spent on social media," explained Riehm. "It could be that girls and boys have different interactions on social media that would lead to more risk for women, but we wouldn't be able to capture that with how we measured social media."

To estimate to what degree mental health problems could be reduced by spending less time on social media, researchers carried out a population-attributable fraction analysis. Essentially, this involved cumulatively reclassifying those in one category of hours spent on social media into the next lowest category.

The findings here suggested that if adolescents used social media for 30 minutes or less per day instead of for more than 30 minutes per day, there would have been 9.4% fewer high internalizing problem cases and 7.3% fewer high externalizing problem cases.

That does not necessarily mean, however, that reducing social media use would result in fewer mental health problems. "A lot more research would need to be done to determine if real changes in social media use would lead to changes in internalizing symptoms," said Riehm.

Such research could take the form of a randomized clinical trial. Riehm cited 1 such trial that has already linked reduced social media use to less depressive symptoms.

However, that study was relatively small and restricted to college students. "Future researchers could consider scaling that up and doing it in a population of adolescents," said Riehm.

Numerous factors might help explain the association between social media use and internalizing problems. For example, adolescents who use social media extensively may have sleep problems and may be at increased risk for cyberbullying, which is strongly associated with depressive symptoms.

As well, lengthy social media use may negatively affect self-esteem, said Riehm.

"Social media has a lot of idealized presentations of people, and constantly being exposed to that might make you feel like you're not living up to what other people are doing. That could affect your self-esteem, which in turn could lead to anxiety and depression."

The current study could not determine whether the association between social media use and internalizing problems is greater for particular platforms, or whether certain user groups are particularly vulnerable, said Riehm.

Families have options when it comes to curtailing social media use. Riehm pointed to the American Academy of Pediatrics' Family Media Use Plan that helps parents set reasonable rules for daily digital media use.

For example, parents can set screen-free zones in the home, establish screen-free times such as during meals, and initiate device curfews, said Riehm.

No More "Likes"?

Social media giants are starting to recognize that their platform features may contribute to mental health problems among young users. Riehm noted that Instagram has been testing the removal of its "likes" function.

"It will be interesting to see if other platforms follow suit and change things as well."

But social media does have potential benefits for teenagers. These include learning about current events, being able to communicate over geographic barriers, and social inclusion for those who may otherwise be excluded in their day-to-day lives; for example, LGBTQ youth.

So what is the optimal amount of social media time for young people? Based on research to date, 30 minutes a day "appears to be a good threshold, at least to start from," said Riehm, although she stressed that "I can't say if that's safe or not."

A limitation of the study was that the exposure and mental health problems were self-reported.

Commenting for Medscape Medical News, Joshua Weiner, MD, a psychiatrist in McLean, Virginia, whose practice is at least 40% adolescents, said that although he always finds studies like this new one interesting, they tend to include so many variables that the design becomes rather complicated.

"I think that makes it hard to really fully appreciate the findings."

Although the authors point out that suicide rates are on the rise among teenagers, Dr Weiner noted that the current suicide rate is not the highest historically.

"Although suicide rates in teens have been on the rise over the last roughly 15 years, they're actually still not as high as they were in the early '90s" in boys aged 15 to 19 years, when social media did not even exist, he said.

He believes these high rates might have been a result of the relatively high level of alcohol use at the time, which disinhibited boys.

Dr Weiner noted that from his clinical experience, girls are more affected by social media than are boys. "Girls are coming in with complaints that are clearly linked to social media."

The rates of internalizing and externalizing problems reported by study subjects are lower than Dr Weiner would have expected. "It's estimated that in general, about 25% of 13- to 18-year-olds will experience an anxiety disorder, and that doesn't even include depression," he said.

The rate of internalizing problems for teenagers "is very high in general," whether or not social media is contributing, he added.

Although the study linked social media use at wave 2 to internalizing problems at wave 3, it doesn't consider that age itself is a factor in rising rates of mental health issues.

"You might not have had issues with anxiety or depression at 13 years old, but you're more likely to have these issues when you're 16, anyway."

However, he agreed that the study did find a progressive increase in the amount of internalizing problems as kids spent more time on social media.

Dr Weiner is convinced that one of the biggest contributors to internalizing problems is sleep deprivation, but that could be a result of staying up to watch television or some other reason not involving social media.

He noted that the study did not differentiate between social media sites. Watching YouTube might be more "benign" than visiting some other platform, he said.

Medscape Medical News also invited Vinu Ilakkuvan, DrPH, a public health consultant and professorial lecturer at George Washington University Milken Institute School of Public Health, Washington, DC, and lead author of another study of social media use and health risks, to comment.[2]

He called the new study well designed and executed, and said it was an important contribution to the literature. He added that using longitudinal data that accounts for prior history of mental health problems is "a key strength" of the study.

Use of social media and widespread sharing of its content "has run rampant and unchecked," Dr Ilakkuvan said, adding that "neither regulation nor research has kept pace."

"Studies like this one are a step in the right direction, particularly if they can help inform programmatic and policy interventions, as well as changes to social media platforms, that could mitigate the negative influence of social media on adolescent health while maintaining or strengthening the potential benefits."

Riehm was supported by a grant from the National Institute of Mental Health Psychiatric Epidemiology Training Program and by a doctoral foreign study award from the Canadian Institutes of Health Research. Dr Weiner and Dr Ilakkuvan have disclosed no relevant financial relationships.

JAMA Psych. Published online September 11, 2019.

Study Highlights

  • Study data were drawn from the PATH study. This study included US adolescents between the ages of 12 and 17 years of age who were recruited into the study between 2013 and 2016.
  • Mental health symptoms during the last year were assessed with the Global Appraisal of Needs-Short Screener. Four or more symptoms on either the internalizing or externalizing scales was considered a positive screen.
  • The main study variable was self-reported average time daily using social media. Researchers assessed how social media time affected internalizing symptoms, externalizing symptoms, or both symptoms as comorbid in the same individual.
  • The study analysis was adjusted to account for demographic variables, past mental health symptoms (to avoid reverse causality), and substance use.
  • 6595 adolescents were analyzed in the present analysis. All were between 12 and 15 years of age at study enrollment, and 51.3% were male.
  • 16.8% of the cohort reported no social media use and 31.8% reported 30 minutes or less of daily social media use. In contrast, 12.3% of adolescents were using social media between 3 and 6 hours daily, and 8.4% of the cohort used social media more than 6 hours daily.
  • There was a linear increase in internalizing and comorbid internalizing/externalizing symptoms associated with increasing time on social media, but the association between social media use and externalizing symptoms alone was not significant.
  • Compared with adolescents who did not use social media, adolescents who reported an average social media use between 3 and 6 hours per day had an adjusted RRR (aRRR) of 1.60 (95% CI, 1.11-2.31). The respective aRRR among adolescents with more than 6 hours of social media use daily was 1.78 (95% CI, 1.15-2.77). Social media use less than 3 hours per day was not significantly associated with a positive screen for internalizing symptoms.
  • Even modest use of social media was associated with a higher aRRR for comorbid internalizing/externalizing symptoms. The aRRR associated with social media use between 30 minutes and 3 hours daily vs no social media use was 1.59 (95% CI, 1.23-2.05). The respective aRRR values for 3 to 6 hours and more than 6 hours of social media use daily were 2.01 (95% CI, 1.51-2.66) and 2.44 (95% CI, 1.73-3.43).
  • A secondary analysis based on sex failed to alter the main study findings.
  • The authors estimate that more than 15% of internalizing and externalizing symptoms could be avoided among adolescents through less use of social media. But they also urge caution regarding the limitations of their research and call for randomized trials to test whether reduced social media time has a salutary effect on the mental health of adolescents.

Clinical Implications

  • In a 2018 poll, 97% of adolescent respondents reported using at least 1 of the 7 most popular social media platforms, and 95% reported owning or having access to a smartphone. One quarter of adolescents believe that social media has a mostly negative influence. Rates of depression and suicidality have increased among US adolescents during the last 2 decades.
  • The current study finds linear increases in internalizing and comorbid internalizing/externalizing symptoms as social media use increased among adolescents, but there was no significant association between social media use and externalizing symptoms.
  • Implications for the Healthcare Team: The current study does not prove causality between social media use among adolescents and mental health symptoms, but it provides evidence to discuss with adolescents during routine screening procedures with the healthcare team.

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