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Depression is common and frequently undiagnosed among college students. Social networking sites are popular among college students and can include displayed depression references. The purpose of this study was to evaluate college students' Facebook disclosures that met DSM criteria for a depression symptom or a major depressive episode (MDE).
We selected public Facebook profiles from sophomore and junior undergraduates and evaluated personally written text: “status updates.” We applied DSM criteria to one year of status updates from each profile to determine prevalence of displayed depression symptoms and MDE criteria. Negative binomial regression analysis was used to model the association between depression disclosures and demographics or Facebook use characteristics.
A total of 200 profiles were evaluated, profile owners were 43.5% female with a mean age of 20 years. Overall, 25% of profiles displayed depressive symptoms and 2.5% met criteria for MDE. Profile owners were more likely to reference depression if they averaged at least one online response from their friends to a status update disclosing depressive symptoms (exp(B)=2.1, p<0.001), or if they used Facebook more frequently (p<0.001).
College students commonly display symptoms consistent with depression on Facebook. Our findings suggest that those who receive online reinforcement from their friends are more likely to discuss their depressive symptoms publicly on Facebook. Given the frequency of depression symptom displays on public profiles, SNSs could be an innovative avenue for combating stigma surrounding mental health conditions, or for identifying students at risk for depression.
Depression is one of the most common health issues impacting the college student population; rates of college students reporting depression have increased 56% in the last six years. [1–3] Given that approximately half of young adults attend post-secondary education, universities are an important setting in which depression can be addressed. Depression often has an onset during the adolescent and young adult years and is associated with negative health and social outcomes. Adverse outcomes include poor academic achievement, increased rates of substance use, co-morbid psychiatric conditions and suicide.[6–10]
Depression is typically diagnosed during a clinical encounter using the Diagnostic and Statistical Manual volume IV (DSM-IV) criteria. Symptoms include depressed mood, hopelessness, and sleep difficulties including both hypersomnia and insomnia.[12–14] For a major depressive episode (MDE), the most common form of depression among adolescents and young adults, symptoms must be present “most every day” during a two week time period. [11, 15] While the DSM-IV criteria are useful in defining depression, diagnosis requires a patient to initiate a clinic visit and report symptoms that trigger the provider's recognition that a mental health assessment is needed.
Despite the prevalence of depression in this population, college students struggling with depression are frequently undiagnosed as many do not perceive a need for help and do not seek clinical services.[16, 17] While 30% of college students report that in the last 12 months they have felt so depressed that it was difficult to function, only 10% of college students report having sought care and been diagnosed with depression. Concerns about the stigma related to mental illness are also associated with less perceived need for help and decreased treatment seeking behavior within this population. Other barriers to help-seeking include lack of knowledge about available services and privacy concerns.
Given the prevalence, consequences and missed opportunities for recognition and treatment of this common mental health problem, new ways of identifying college students at risk and referring them to appropriate services are warranted. Social networking web sites (SNSs) may present innovative opportunities to identify college students at risk. Over 90% of college students use SNS; Facebook.com is the most popular SNS in this population.[19–21] SNSs are commonly used for social dialogue among peers, and previous work has illustrated that references to personal information or health risk behaviors are common.[22–24] One popular feature of Facebook is the “status update” in which personally written text describing the profile owner's current experience or emotion are displayed along with the date and time of disclosure. Anecdotal reports suggest some college students discuss mental health concerns on status updates, examples include “Mary is feeling really sad this week,” or “Dan is too depressed to sit in class.” The prevalence of such disclosures is unknown. As the majority of college students' profiles are public, these status updates are available to students' peers, as well as others within that university Facebook network such as college health providers.
If college students use Facebook profiles to disclose symptoms of depression, these disclosures could be viewed by peers as well as a larger online audience who may be able to facilitate identification or referral for mental health concerns. Before such outreach or potential interventions can be considered, the prevalence and content of such disclosures must be assessed. The purpose of this study was to evaluate college students' disclosures of depression symptoms on Facebook with three specific goals. Our first goal was to describe displayed depression symptoms on Facebook profiles, including prevalence estimates. We hypothesized that concerns about stigma related to reporting depression symptoms in a public online format would lead to low prevalence of depression symptoms. Our second goal was to assess the prevalence of profiles whose display of symptoms met criteria for a major depressive episode by applying standard DSM diagnostic criteria to one year of Facebook status updates. Our third goal was to determine associations between displayed depression symptoms on Facebook and other demographic or Facebook use characteristics.
This study was conducted between July 1, 2009 and October 1, 2010 and received an IRB exemption from the University of Wisconsin.
This study was conducted using the SNS Facebook (www.Facebook.com) as it is the most popular SNS among our target population. Profiles were included in this study if they were publicly available within our university Facebook network, self-reported their age as over 18 years and provided evidence of profile activity in the last 30 days. In order to evaluate current college students we selected publicly available profiles from college students who had completed their sophomore and junior years of college (rising juniors and seniors).
We used the Facebook search engine to identify profiles within our university network that displayed a college graduation year of 2010 or 2011 and high school graduation year of 2006 or 2007. Similar to other online search engines, at the time of this study Facebook presented search results in non-alphabetical, non-age based, non-numerical order in lists of up to 500 profiles. profiles were thus assessed sequentially for eligibility. Our goal for this evaluation was to assess 200 profiles from students who were currently in a university setting, thus we focused on students who had completed their sophomore and junior year.
The coders first viewed the “information section” of the profile to obtain demographic information and information describing Facebook use. Second, to evaluate depression symptom disclosures, coders reviewed each profile's history of status updates from the date of evaluation through the same date from one year prior. For each status update that included a depression symptom, coders recorded verbatim text and the date of disclosure. Status updates that referenced a person other than the profile owner (i.e. “Matt is sitting next to me in class and he looks bummed”) were not considered personal references and were excluded. Third, for profiles in which a status update disclosed a depression symptom, investigators evaluated whether other Facebook users responded to that depression symptom in “comments” for that status update. Facebook users can provide comments as public feedback to status updates and pictures. For example, if a profile owner displays a status update: “I am really feeling down this week,” then responses to that status update may include comments such as “I hope you feel better,” or “I'm having a bad week too!” If comments were present, they were counted and recorded verbatim.
Two investigators participated in training and conducted all profile evaluations for this study. Training included review and practice with codebooks used in previous work with Facebook. Coders then reviewed Diagnostic and Statistical Manual (DSM) IV criteria for MDE and participated in developing the codebook with keywords and synonyms. A final training exercise involved a pilot evaluation of profiles using these DSM-IV keywords and synonyms before collecting data used in this study.
References to depression symptoms were defined using the symptoms outlined in the DSM criteria for a major depressive episode (MDE). We chose established clinical criteria as the basis of our research codebook to provide the most clinically relevant, objective framework for profile evaluation. The criteria for MDE include depressed mood, loss of interest/pleasure in activities, appetite changes, sleep problems, psychomotor agitation or retardation, energy loss, feeling worthless or guilty, decreased concentration or suicidal ideation. Status updates were considered as a depression reference if they fit one of the described depression criteria by keyword or a synonym. For example, one symptom keyword of major depression is “hopeless,” therefore a status update stating “I feel hopeless” would be coded as a reference to depression. The term “giving up” is a synonym of “hopeless,” therefore, a status update disclosing “I feel like giving up” would be coded as a reference to depression. Comments that referenced the common experience of having a bad day such as “having a lousy day” or “wish this day would be done!” did not meet criteria as a depression symptom.
References made in status updates to sleep difficulties were also coded. Sleep difficulties are associated with MDE and often described as “sleep problems: too much sleep or difficulty getting to sleep.” Our pilot evaluations revealed that references to sleep difficulties often included disclosures regarding “feeling tired” without further discussion of whether the profile owner was sleeping too much, sleeping too little or had other extraneous circumstances impacting sleep, such as studying. Further, our pilot evaluations also revealed that prevalence of displayed comments related to sleep surpassed the prevalence of displayed comments related to other depression symptoms, which is not surprising given that 80% of college students report feeling exhausted at least once in the past year. To avoid overestimating the prevalence of depression symptoms by counting profiles that only disclosed sleep difficulties, we coded sleep-related disclosures separately.
A diagnosis of a major depressive episode is made based on both symptoms and timing of symptoms, and Facebook status updates include a date and time stamp. Thus, we examined all status updates that met criteria for depression symptoms by date. We used DSM criteria for a major depressive episode: five or more depression symptoms must be present during the same 2 week period, and at least one of the symptoms is depressed mood or loss of interest/pleasure. Given that we could not estimate how long the displayed depression symptom had been present based on the status update, we modified this criteria in applying it to Facebook. In keeping with DSM criteria, within the same 2 week period we required five or more status updates that met DSM criteria as a symptom for depression, and at least one of the updates was depressed mood or loss of interest/pleasure.
From each profile that met inclusion criteria, we recorded demographics including age, gender, graduation year and self-reported “relationship status” of whether the profile owner was single or in a romantic relationship. This information is presented in a standard format on Facebook profiles and displayed at the profile owner's discretion.
We also gathered data on the profile owner's Facebook use patterns. First, we recorded the number of Facebook “friends” displayed by the profile owner; Facebook allows users to link their profile to others' via “friending.” Second, we recorded the number of days since last Facebook activity as a measure of recent Facebook use. Fewer days since last activity suggests more frequent logging in to Facebook.
A 10% random subsample of profiles were evaluated by two coders and Cohen's kappa was used to evaluate the extent to which there was intercoder reliability in the presence or absence of depression symptoms. The kappa for displayed depression symptoms on Facebook was 0.79, indicating substantial agreement.
Because of the potential for a profile owner to disclose suicidal ideation on a status update, we developed a protocol to respond to any imminent threats immediately and alert appropriate referral agencies. This protocol was developed in partnership with our University Health Services.
All statistical analyses were conducted using STATA version 9.0 (Statacorp, College Station, TX). Bivariate analyses were conducted to examine the relationship of the presence or absence of depression disclosures on Facebook with both demographics and Facebook use characteristics. Pearson chi-square tests were used for categorical comparisons and bivariate regression models were used for continuous measures. As the number of Facebook friends was not normally distributed, we used the square root of the number of friends. The number of days since last Facebook update and the number of references to sleep difficulties were treated as counts and analyzed using negative binomial regression models.
We then examined the relationship of the number of depression references with demographics and Facebook use variables using negative binomial regression models. Analyses were conducted using forward stepwise regression and confirmed using backward stepwise regression.
We evaluated 342 profiles to reach our goal of 200. Most profile exclusions were due to no age listed on the profile (n=95) or profile security set to “private” (n=66). Of the 200 included profiles, 43.5% were female and the average age was 20 years. Approximately 72% of participants reported their relationship status and nearly 41% described themselves as in a relationship. The average number of friends displayed on each profile was 449.5 (SD 237.2), the range was 66 to 1405. The average date of last activity on Facebook was 5.98 (SD 6.9) days. (Table 1)
Overall, 25% of profiles disclosed one or more depressive symptoms on status updates. Overall, the most common type of depression symptom reference was to depressed mood, a total of 50 references fit this category. Feelings of guilt or worthlessness were present on 15 references. Indecisiveness was present in 6 references, and loss of energy in 5 references. The symptoms of decreased interest or pleasure in activities, change in appetite and psychomotor agitation were present in only 1 reference each. No references to suicidal ideation were present in our data. Using DSM criteria for a major depressive episode, we found that 5 profiles (2.5%) met these criteria. Table 2 shows the categories of depression references and examples text from these references.
Table 3 includes bivariate comparisons of the presence or absence of displayed depression symptoms by the participants' demographic and Facebook activity characteristics. College juniors were more likely to display depression symptoms (36%) compared to sophomores (14%) (p<0.001).
Participants who displayed depression symptoms were more likely to have updated their Facebook profile more recently (p<0.001). Those who displayed depression symptoms on average had updated their Facebook profile 3.2 days (SD 3.7) before the profile was evaluated, those who did not display depression had last updated their profile 6.9 days ago (SD 7.6).
References to sleep concerns were common, with 41.5% of profiles displaying these disclosures. There were a total of 268 references to sleep in our dataset. Half of participants who displayed depression symptoms also displayed references to sleep difficulties, among participants who did not display depression symptoms only 30% displayed sleep difficulties (p<0.001).
In adjusted negative binomial models, college juniors reported over three times more depression references than sophomores (exp(B)=3.1,p=0.001). Further, receiving responses to a displayed depression reference was associated with increased numbers of depression references. For each additional response from a Facebook friend to a displayed depression reference, a student displayed twice as many depression references (exp(B)=2.1, p<0.00). Last, each additional reference to sleep concerns was associated with an increase in the number of status updates that reference depression (exp(B)=1.37, p<0.00).
Our results suggest that displayed comments that meet criteria as symptoms of depression are disclosed on Facebook by approximately 25% of college students. As over 80% of profiles evaluated for eligibility were publically available, and data suggests over 90% of college students maintain a Facebook profile, our results are likely generalizable within this university setting. Further, a small proportion of coded Facebook profiles displayed depression symptoms that meet our proxy DSM criteria for a major depressive episode.
In creating a SNS profile college students may give researchers and health care providers insight into aspects of their behavior that are not always apparent in offline life. Adolescents report that they often disclose more about themselves on SNSs than they do in person . Given that over 90% of college students maintain a Facebook profile, and that Facebook is a socially shared and socially constructed document, it may seem obvious that profile owners cannot stray too far from reality in constructing their online identity. However, creating a profile allows profile owners to selectively choose what aspects of their identity they wish to display and which they wish to avoid putting into public focus. Despite the potential for stigma surrounding mental health symptoms or diagnoses, a quarter of profiles in this study publicly displayed depression references. Our study does not provide evidence of the face validity of displayed references that meet criteria for depression symptoms, but it does provide prevalence estimates and rich description of how these status updates are displayed.
Our findings suggest that 2.5% of profiles displayed depression symptoms consistent with our proxy defined DSM diagnosis of a major depressive episode, including timing and symptom category. These prevalence rates for both depression and depressive symptoms are similar to previous work in which such disclosures were self-reported. A recent study of adolescents and young adults found that over a quarter of participants reported at least one core DSM-IV symptom of major depressive disorder. Another study among college students found that 33% reported symptoms of depression, but only 2% reported symptom duration consistent with DSM criteria for a diagnosis of MDE. The point prevalence of MDE in older adolescents has been estimated to be approximately 3%. As much of the art and science of mental health diagnoses involve assessing symptom patterns over time, Facebook may present a novel way to investigate patterns of depression disclosure either for diagnostic or treatment purposes. While we would not argue that Facebook should be used to formally diagnose depression, displayed information may allow identification of an at-risk student and prompt a further clinical evaluation. Recent media stories highlight tragic suicides of adolescents and young adults that were displayed on SNSs prior to being carried out; illustrating the urgent need to better understand the validity of displayed references to mental health concerns on SNSs.[30, 31]
Our findings suggest several associations between Facebook use characteristics and display of depression symptoms. First, students who displayed more recent Facebook activity were more likely to display a reference to depression. It is possible that students experiencing depressive symptoms place greater investment in SNSs as a communication outlet as it could be viewed as a safe, indirect outlet for emotions. Second, references to depression were more commonly displayed on Facebook profiles in which a response by another Facebook user was generated. This suggests that those who receive reinforcement to a depression disclosure from their online friends may be more likely to discuss their depressive symptoms publicly on Facebook. From another perspective, this also suggests that depression disclosures on Facebook often elicit responses from peers who view these references. This is supported by previous work which suggests that students often report willingness to refer their peers for help and over half of college students are interested in learning how to help a student in distress. [3, 32, 33] As the total number of Facebook friends was not associated with increased depression disclosures, this suggests that it is not the size of one's online social network, but their involvement which may prompt peers to display depressive symptoms. Students with a more involved online social network may feel more comfortable disclosing depressive symptoms on their profiles, and may perceive more opportunity to do so. This is supported by a recent study in which older adolescents who received positive feedback on their SNS profiles reported enhanced self-esteem and sense of well-being. Alternatively, these students may have more limited offline social networks and thus invest more heavily in their Facebook social network. A last consideration is that those who use Facebook more often may be more likely to display more information in general, and thus more likely to display depression references.
There are several potential limitations of our study. First, we evaluated Web profiles from only one SNS and one university. The extent to which findings could be generalized to other Web sites or other adolescent populations is not known. Second, because we focused on college students, generalizing results to other young adult populations may not be warranted. Since college students are a key population in which mental health problems are common, consequential and often undiagnosed, this was our population of choice for this evaluation. Third, our study focused on publicly available profiles, it is unclear whether increased privacy settings would increase or decrease the likelihood of disclosing depression symptoms. Our goal in assessing publicly available profiles was to examine profiles that could be accessed by any peer, parent or college health provider. Fourth, the validity of these displayed status updates suggesting depression symptoms is unclear at this point. Without clinical context including duration, severity, and frequency of the displayed symptoms, formal diagnosis cannot be made without further clinical evaluation. Future study should evaluate associations between displayed depression symptoms and self-reported depression symptoms using a clinical scale.
Despite these limitations, our study has important implications for improving mental health care for college students. First, given the prevalence of references to depression disclosed on Facebook, the popularity of this website among college students, and the ability to track disclosures and symptoms over time, Facebook may present an innovative opportunity to identify students at risk for depression. The wide accessibility of SNSs could allow for involvement of family members, university representatives, or even peers as a means of helping to identify students who would benefit from further screening via a clinical encounter to assess depression. Because Facebook is a peer communication tool, peers may be both able and motivated to identify at-risk students using Facebook. As seen in our findings that students often displayed responses to depression references, students are a ready and willing audience to help peers in distress. [3, 32, 33] Given that Facebook is typically perceived as a peer communication tool, enlisting peers in efforts to identify at risk students may reduce concerns about privacy violations.
Second, SNSs may provide new opportunities to increase student help-seeking behavior. A recent study evaluated an interactive web-based program designed to screen students for depression and suicide risk. After the initial online screening, 24% of students entered into an online dialogue with a counselor, 19% later attended an in-person session with the counselor and 14% entered a treatment program. SNSs may provide an innovative venue to provide access to online screening and follow-up resources, and could be seen as a “safe” venue in which to establish a therapeutic relationship. It is possible that such screening could be triggered by the content of a SNS profile. When Facebook users view their profile, advertisements triggered by keywords present on the profile are displayed at the side of the profile. Based on the content of a students' profile, anecdotal observations show that students are already seeing pop-up advertisements for weight loss products, beauty products, even casino-themed online games. University counseling centers could utilize this service to link messages about counseling services or links to online screening to keywords such as “depressed” or “hopeless.” This method would deliver the message in a targeted manner that still protected the privacy of the profile owner.
Third, it is possible that SNSs have potential to impact college students' views regarding depression. Given the frequency of depression symptom displays on public profiles, SNSs could be an innovative avenue for raising self-awareness and combating stigma surrounding mental health conditions. We found responses to displayed symptoms were frequent, positive and supportive. Despite the potential for stigma related to mental illness, Facebook appears to be a venue in which personal disclosures of depression symptoms is acceptable. It is possible that the social support provided on Facebook is already impacting college students' experiences with depression. Older adolescents often report a preference to cope with mental health problems alone or with help from friends, rather than making use of formal sources. Social support has also been shown to have a buffering effect against depression among students. It is possible that the support provided by online peers through Facebook may complement resources provided by university counseling centers without increasing the burden on these limited campus resources.
To our knowledge, this is the first study to describe mental health disclosures on a publicly accessible SNS. Future studies could evaluate associations between displayed depression symptoms and self-reported depression symptoms using a clinical scale, or how to design effective interventions using the health information displayed on SNSs. All of these intervention ideas hinge on designing programs that are acceptable to students and respect their privacy and confidentiality. Given the personal and potentially stigmatizing nature of mental health disclosures, proper attention to privacy will be critical both in research and potential interventions involving SNSs.[37, 38] There is reason to be optimistic that proper attention to privacy and acceptability may yield useful programs, a study assessing a web-based intervention program found that among students with an un-met need for mental health care, over 90% reported interest in or intention to use the program. However, with the difficulty in identifying students at risk for depression and the potential negative consequences of untreated depression, we cannot afford to ignore public health opportunities to reduce the burden of mental illness in this population.
Funding for this study was provided by award K12HD055894 from the NICHD. The authors would like to thank Mahaya Clark and Lyn Turkstra, PhD for their assistance with this project