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 [27
]. 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.[28
] 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.[29
] The point prevalence of MDE in older adolescents has been estimated to be approximately 3%.[15
] 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
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
] 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.[34
] 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
] 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.[35
] 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.[33
] Social support has also been shown to have a buffering effect against depression among students.[36
] 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
] 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.[39
] 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.