From the Editor

Politicians tout their opinions on social media. Celebrities use it to tell us about their lives. And for everything from cute kid pics to debates over big issues, social media is part of our way of communicating with the world.

But what are the implications to the mental health of adolescents? Many have an opinion, but what can we glean from the literature? This week, we have a couple of selections. In the first and main selection, we look at a review paper from CMAJ. Dr. Elia Abi-Jaoude (University of Toronto) and his co-authors consider the literature on social media. Then, pulling the different studies together, they offer some clinical advice.

social_media_picSocial media: many options, many problems?

In the second selection, we look at an essay by author Susanne Antonetta. She discusses her psychosis and recovery. “There’s difference between psychosis and physical ailments: In the case of psychosis, no one is likely to stop by with a casserole.”



“Smartphones, social media use and youth mental health”

Elia Abi-Jaoude, Karline Treurnicht Naylor, and Antonio Pignatiello

CMAJ, 10 February 2020

In the last decade, increasing mental distress and treatment for mental health conditions among youth in North America has paralleled a steep rise in the use of smartphones and social media by children and adolescents.

In Ontario, the proportion of teenagers reporting moderate to serious mental distress increased from 24% in 2013, to 34% in 2015 and to 39% in 2017, with parallel increases in health service utilization. Inpatient hospital admissions of children and adolescents for mental health reasons increased substantially across Canada between 2007 and 2014, while admissions for other medical conditions in this age group decreased by 14%. Between 2009 and 2014, admissions to hospital for intentional self-harm increased by 110% in Canadian girls. Suicide is now the second leading cause of death for Canadian youth. A recent analysis of survey data found the 12-month prevalence of suicidal ideation, attempts and nonsuicidal self-injury to be 8.1%, 4.3% and 8.8%, respectively, among adolescents aged 14 to 17 years, with all rates being higher in girls…

At the same time, social media use has increased markedly. In the US, the proportion of young people between the ages of 13 and 17 years who have a smartphone has reached 89%, more than doubling over a 6-year period; moreover, 70% of teenagers use social media multiple times per day, up from a third of teens in 2012. The percentage of Ontario’s teenagers who reported spending 5 or more hours a day on social media increased from 11% in 2013, to 16% in 2015 and to 20% in 2017…

We review the evidence that links smartphone and social media use with mental distress and suicidality among adolescents.

hsc-docElia Abi-Jaoude

So begins a new paper by Abi-Jaoude et al.

The authors do an extensive review of the literature; the paper has 68 references. They look at several aspects of mental health and social media by focusing on seven questions.

“How has use of social media been shown to affect adolescents’ sense of self?”

The authors find several papers of note:

  • “Two cross-sectional surveys of American and German university students, respectively, found that students who spent more time on the social media platform Facebook were more likely to endorse feeling envy or sensing that others in their social network were better off than they were.”
  • “A systematic review of 20 studies found that use of social media was associated with body image concerns and disordered eating.”
  • “In a randomized study, female participants reported more negative mood after just 10 minutes of browsing their Facebook account compared with those who browsed an appearance-neutral control website.”

“Does social media addiction exist and can it affect mental health?”

They consider relevant papers but find a lack of agreement on basic definitions:

“Several cross-sectional studies have shown that high proportions of youth appear to be addicted to their smartphones, but there is no standard or agreed-upon definition of smartphone or Internet addiction; studies have used different definitions and scales, varying from those that rely on behavioural addiction criteria, to measurement of the extent of functional impairment and level of device use. As such, reported prevalence rates are highly variable.”

They note a systematic review paper considering Internet addiction and self-harm, finding a link.

“Can social media promote self-harm?”

They note that self-harm images can be met with positive comments.

“Such findings show the potential for mental illness romanticizing and messaging that normalizes self-harm among youth. Indeed, a systematic review that included 26 studies (using qualitative, descriptive or cross-sectional methodology) found that social media platforms included normalization of self-harm behaviour, discussions about practical issues regarding suicidality and live depictions of self-harm acts. At the same time, there were also positive elements, including providing a sense of community, suggestions for seeking treatment and advice on stopping self-harm behaviour.”

“Do the effects of smartphones on social skills affect mental health?”

“Youth do increasingly interact online rather than in person, and smartphones can interfere even with face-to-face interactions via what has been termed ‘phubbing’: attending to one’s phone when in the presence of others. A recent empirical field study using experience sampling in 304 participants showed that even the mere presence of phones on a table caused participants who were randomly assigned to that condition to feel more distracted and have lower enjoyment during social interactions compared with those who were randomized to putting their phone away.”

“Does sleep-loss associated with use of social media affect mental health?”

Drawing on US survey data, they note that adolescents getting insufficient sleep appears to be increasing, “40% sleeping less than 7 hours most nights in 2015.” An Ontario study involving more than 5 000 found a majority (63.6%) of those 11 to 20 years slept less than recommended, and that less sleep was tied to social media use.

They summarize a couple of studies:

  • “In a 14-day, randomized, crossover experimental study under well-controlled conditions, use of electronic screens before bedtime was shown to disrupt sleep in multiple ways: longer time to fall asleep and decreased evening sleepiness, reduced melatonin secretion, circadian clock delay, reduced amount and delay in rapid eye movement sleep, and reduced next-morning alertness.”
  • “A systematic review and meta-analysis that included 20 studies on the association between portable screen-based media devices and sleep outcomes found that use of media at bedtime was associated with decreased duration and quality of sleep and excessive daytime sleepiness. Of note, the mere presence of portable screen-based media devices in the bedroom was shown to disrupt sleep, possibly related to the temptation to check media devices when they are present or owing to a conditioned response involving increased arousal.”

“Are some individuals more susceptible to mental health effects than others?”

“Girls and young women tend to spend more time on social media than boys do, have more exposure to cyberbullying and show tendency to experience more mental health effects, which is consistent with recent epidemiologic trends indicating that depressive symptoms, self-harm and suicidality have increased among young females in particular.”

The authors note that other studies have suggested the issue is more nuanced.

“A structural equation modelling analysis of a cross-sectional survey of 910 high school students in Belgium found that, among girls, passive use of Facebook had a negative impact on mood but active use had a positive impact on perceived online social support, which in turn had a positive impact on mood.

“However, for boys active site use had a negative effect. A systematic review of 70 studies found that while social media use was correlated with depression, anxiety and measures of well-being, effects could be both detrimental (such as from negative interactions and social comparison) and beneficial (such as through social connectedness and support) depending on the quality of interactions and individual factors.”

“How might physicians use this evidence to inform their practice?”

They offer some practice advice:

  • “Clinicians may choose to advocate for a harm reduction approach, suggesting reduced use of social media and the Internet rather than abstinence for youth, given evidence that suggests prolonged use is associated with poorer mental health.”
  • “Encouraging parents to be proactively involved in limiting children’s and teens’ use of smartphones and social media may be helpful, given that social media use appears to become problematic when it surpasses 1 to 2 hours daily…It is also worth reminding parents that they model smartphone use with their own behaviour…”
  • “Youth and their families can be encouraged to set boundaries for smartphone and social media use. These could include such measures as using social media only for set times, and preferably only in common living areas in the home”
  • “Sleep hygiene measures specific to social media and smartphone usage are crucial… These would include avoiding use of electronic screens within 1 to 2 hours before bedtime, and not having portable, screen-based media devices in bedrooms overnight.”
  • “A motivational interviewing approach may be useful to help young people start to make changes in their pattern of online behaviour… This approach should involve open, nonjudgmental exploration of all aspects of a youth’s digital life, including positive and negative. Some youth might benefit from habit reversal training to address compulsive use, including having daily ‘nonscreen time’ that can be progressively increased.”

A few thoughts:

  1. This is a good, important, and practical paper.
  1. The authors do a real service in their summary of the literature.
  1. They also offer tangible suggestions for clinicians. Nice.
  1. In particular, I like the suggestions around sleep hygiene – a subject that is easy to raise with patients of all ages.
  1. There is an active debate about the impact of social media on mental health. Nature has just featured two views on this topic, Scrutinizing the effects of digital technology on mental health.” Jonathan Haidt (New York University’s Stern School of Business) debates Nick Allen (University of Oregon’s Center for Digital Mental Health).

Haidt argues: “In conclusion, digital media in general undoubtedly has many beneficial uses, including the treatment of mental illness. But if you focus on social media, you’ll find stronger evidence of harm, and less exculpatory evidence, especially for its millions of under-age users.”

jonathan_haidt_2012_03Jonathan Haidt

Allen responds: “focusing only on its potential harmful effects is comparable to proposing that the only question to ask about cars is whether people can die driving them. The harmful effects might be real, but they don’t tell the full story. The task of research should be to understand what patterns of digital-device and social-media use can lead to beneficial versus harmful effects, and to inform evidence-based approaches to policy, education and regulation.” 

You can find the debate here:


“Even When I’m Psychotic, I’m Still Me”

Susanne Antonetta

The New York Times, 21 February 2020

Last September, I believed my brain was on fire. Not in some metaphorical way. It was, as far as I was concerned, on fire.

I am bipolar and I was hallucinating. My hallucinations can be sensory, like the brain burn, but many are auditory – I know hallucinations are coming when I hear birds speak. I can tell you what the birds say, but what matters is how intensely personal it is, being shouted at by a fierce small crowd: persist persist persist from one, six degrees yes yes yes from another.

I couldn’t sleep in all the chatter.

antonettaauthorphoto1copy1500x2200Susanne Antonetta

So begins an essay by Antonetta.

Doctors, and the occasional friend, kept telling me something meant to be cheering: ‘This is just a disease, the same as a broken bone or a bout of pneumonia.’ As though my antipsychotic could just as easily be penicillin. I’ve heard this statement in one form or another for several decades, since my diagnosis at age 29.

She explains her hesitancy about the explanation:

I don’t accept this mechanistic view of the brain, which suggests that if you pump in drugs (at levels often determined by drug company-funded research), the cogs will start working smoothly again. This model dismisses patients’ individual experience of medications, which vary wildly. It overwrites their personhood, their lived experience, the degree to which they wish to be medicated. Often at the heart of the medical model is the view that patients are the last to understand their own needs and psyches.

She also notes the difference in experience between those with physical and mental health problems:

There’s another difference between psychosis and physical ailments: In the case of psychosis, no one is likely to stop by with a casserole. No one honestly thinks of you as having a broken bone, and no one acts as if you do. As my hallucinations went on, I had to go back on Seroquel and take medical leave from teaching. For several months I remained shaky, medication-fogged, sometimes crying for no reason, sometimes hearing birds talk to me again.

During this time in my life many people in my life disappeared.

She considers the content of her hallucinations, which she feels is meaningful, if born of illness.

She ends:

My hallucinations have ended and I’m gradually returning to a lower level of medication. I’m still unpacking for myself what this experience of mine meant, how it still moves in some way inside me. It’s elusive. I do know I want to peel back this isolation and forced secrecy. I must if I’m going to live honestly in the world. It’s almost as disorienting as delusion, going from that crowded and noisy place of psychosis to this silence.

A few thoughts:

  1. This is a moving and personal essay.
  1. Unlike some patients, Antonetta doesn’t dismiss her experience. Is this helpful in her coming to terms with her illness?
  1. It’s difficult not to be moved by her description of the isolation she experienced during the most acute parts of her illness – a reminder that many things have changed, but stigma continues to exist.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.