From the Editor

Politicians tweet about townhall meetings; celebrities put vacation pictures on Instagram; your cousin in Europe has her own YouTube channel.

Our world is very different than it was just a few short years ago. (Fun fact: Facebook – a decade and a half old – claims to have more than 2 billion active monthly users.)

But how has social media affected those with mental illness? While this is much discussed in the media, there is little in the literature. In this week’s Reading, we consider a new paper that looks at social media and mental illness, in particular psychosis. Tweet this: the University of Manchester’s Natalie Berry and her co-authors didn’t find a connection between use of social media and increased paranoia.

BELCHATOW POLAND - MAY 02 2013: Modern white keyboard with colored social network buttons.

In this week’s Reading, we consider this new paper from Acta Psychiatrica Scandinavica. We also wonder about the role of the Internet and social media for those with psychosis, drawing from a Psychiatric Services paper.

Also, the University of Toronto’s Dr. Ivan Silver writes a letter to the editor about a previous Reading.



Social Media and Illness

“Social media and its relationship with mood, selfesteem and paranoia in psychosis”

N. Berry, R. Emsley, F. Lobban, S. Bucci

Acta Psychiatrica Scandinavica, 10 September 2018 Online First – Open Access

The use of social media websites such as Twitter, Facebook and Instagram is widespread. Social media websites allow individuals to construct profiles in which they can maintain and create social networks, circulate details about their daily lives and respond to posts written by others. Rates of social media use by people with severe mental health problems such as psychosis are lower than the general population based on small‐scale studies.

People with mental health problems already use social media websites to self‐manage their mental health. For example, social media can be a helpful coping mechanism to facilitate self‐expression and communication with others with similar experiences and to access motivational content. Clinicians have observed occasions where online communication has been beneficial for clients’ with SMI through accessible peer support and ability for anonymous self‐expression. Individuals are amenable to the idea of receiving mental health support via social media websites and have suggested the inclusion of social media components, such as moderated discussion forums, in future interventions.

Despite some evidence for the potential therapeutic benefits of social media use, social media engagement may also be harmful for an individual’s mental health and wellbeing. For example, several studies have reported a significant link between high social media use and low mood and depression. However, others have found no evidence of a link between social media use and mood. Mixed findings have also been reported for the relationship between social media use and self‐esteem. Systematic reviews have highlighted that conclusions cannot yet be drawn and further robust research is warranted. It has been proposed that people with psychosis may be particularly vulnerable to paranoid ideas after using social media websites, and evidence from case reports suggests the development and exacerbation of symptoms associated with severe mental health problems after social media engagement. Individuals with psychosis may be more affected by content consumption on social media in comparison with those without psychosis due to the posts written by others often being open to individual interpretation. Specifically, people with psychosis can have cognitive biases that can lead them to misinterpret the actions and behaviours of others as threatening or self‐referent. Therefore, a virtual world where one is continuously observing the content written by others may facilitate individuals with psychosis to observe and become suspicious by others actions online. However, much of the current research has relied on participants with severe mental health problems retrospectively self‐reporting whether they feel their use of social media leads to paranoia. More recently, Bird et al. reported that the experience of negative affect during social media use correlates with paranoia severity. The lack of robust study designs and larger‐scale research prevents conclusions from being drawn.

natalie-berry Natalie Berry

So begins a new paper by Natalie Berry et al.

Here’s what they did:

  • Using the experience sampling method (a novel approach), the authors tried to capture momentary assessments of mood, self-esteem, and paranoia utilizing various scales.
  • Participants were recruited through volunteer websites and through NHS mental health services.
  • They were included if they had a “clinician-verified experience of first episode psychosis” or if they had received a DSM-IV schizophrenia-spectrum diagnosis. They needed to be 18 or older and to speak English. They used Facebook or Twitter at least three times per week.
  • Over a six-day period, different scales were used to measure mood (the Positive and Negative Affect Schedule), self-esteem (the Rosenberg Self-esteem scale), paranoia (the Paranoia Scale), as well as social rank (the Social Comparison Scale).
  • Statistical analyses were done, including t-tests.

Here’s what they found:

  • A total of 46 people participated, 19 with psychosis and 25 non-clinical.
  • Demographically: the mean age of both groups was similar, in the early 30s (clinical: 33.7 and non-clinical: 35.4); participants were mainly female (63% and 56%); ethnically they were British white (95% and 84%); employment status differed between the groups (86% and 7% unemployed).
  • Facebook was used by everyone; in contrast, Tumblr and Flickr weren’t popular with the clinical or non-clinical participants (just 11% and 4% used these sites, respectively).
  • Out of the 1584 assessments, 1084 were completed (for a response rate of 68.4%).
  • “General social media use across the study duration was not significantly related to participant age, but was associated with mental health status, with participants in the clinical group reporting lower levels of social media use in comparison with participants in the non‐clinical group…” Gender didn’t seem to influence social media use.
  • Does use predict self-esteem, mood, and paranoia? “Social media use negatively predicted PA [Positive Affect] and positively predicted NA [Negative Affect]. However, social media use did not predict self‐esteem or paranoia.” (A multilevel logistic regression analysis confirmed that use predicted mood, not the other way around.)
  • Did the type of social media use affect the user? “Content consumption and direct communication were not found to predict PA, self‐esteem, paranoia or perceived SR [Social Rank].”
  • Do social media use and behaviours differ between people with and without psychosis?Clinical participants were less likely to use social media than non‐clinical participants (OR = 0.5366…).”
  1. This is an interesting study.
  1. The topic is great. (In my Monday afternoon clinic, the only patient who wasn’t using a single device in the waiting room was the young woman juggling both an iPhone and an iPad.)
  1. The study only had an of 19, in terms of people with psychosis. The paper thus offers some data – but perspective is important.
  1. The study had a narrow time period – just a handful of days. Would the results have been different if those with psychosis were sampled three or six months later?
  1. Are there clinical implications here? The authors think so.

Despite finding that psychosis did not moderate the impact of social media use per se, reductions in mood after social media use are likely to be more damaging for people with psychosis due to reporting lower levels of mood initially. The negative consequence of social media engagement in both groups highlights the importance of continued consideration of the impact of social media in mental health settings. Specifically, clinicians should ensure that they are aware of and explore any potential issues clients face when using social media, particularly with regard to online self‐disclosures.

  1. It’s important to take a balanced approach when considering mental illness and technology. Over the years, my patients have spoken positively about information they have found on the Internet, apps they have used for everything from taking medications to charting their mood, and patient forums that have helped them feel more connected. That’s not to suggest that cyberbullying isn’t a problem; it is to suggest that social media may present us with opportunities as well.
  1. To the last point: a brief report just published sees an important role for the Internet and social media. In “Digital Trajectories to Care in First-Episode Psychosis,” Michael L. Birnbaum of Northwell Health and his co-authors asked people who had experienced first-episode psychosis in the past two years to complete a questionnaire on Internet use, with 112 participants between the ages of 15 and 35.

michael-birnbaum-five-things-depression-mood-disorders_Michael L. Birnbaum

They found:

  • 9 out of 10 used the Internet daily.
  • Social media was checked on average 9.0 times daily, spending 1.8 hours daily online.
  • While participants waited more than 9 months to report symptoms, 76% were open to the possibility of receiving online mental health help or support via the internet.

They write:

The Internet and social media may offer opportunities to improve pathways to care through innovative identification, outreach, and engagement strategies. Our data reinforced several relevant findings. Online resources, including Google, Facebook, and Twitter, were an important part of daily life for participants with early psychosis. Online activity often predated illness onset and continued throughout the DUP, which offers the prospect of earlier intervention. Importantly, participants with early psychosis expressed positive attitudes toward Internet- and social media–based intervention efforts.

The paper can be found here:


Changing Doctors

To the Editor:

I read with great interest your Reading of the Week: “How to Change Docs? Send Them a Letter.” As someone who has spent the last 20 years trying to figure how to optimize physicians’ clinical practices, I think there are several general teaching points that the paper raises.

  1. The study highlights the issue that physicians require their own data and ideally feedback on their actual clinical practices in order to change their practices.
  1. The study may also be saying that receiving written feedback on just one clinical performance issue at a time may be optimal to initiate changes in practice.
  1. The inadvertent decreased prescribing of quetiapine by family physicians when the prescribing was appropriate highlights that written feedback may not be sufficient to optimally change practice.
  1. The study parallels research on the use of reminders (computer) that have small to modest effects on changing physician behavior. See:
  1. Interestingly, sternly written feedback letters were not included as a change method in the many reviews on changing physicians’ behavior that have been published in the past 20 years. See: and
  1. I agree with Dr. Gratzer that physicians may accommodate to or “tune out” repeated letters highlighting sub-optimal personal practice data (warning fatigue). This suggests that we may need to vary feedback practices to physicians in order to optimize the impact.
  1. We need to be advocates to Ministries of Health and to hospital leadership to increase the amount of data physicians receive on their practices with opportunities to discuss the feedback and a change plan with clinical leaders and peers.

Ivan Silver, MD, MEd, FRCPC

Professor of Psychiatry, University of Toronto


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