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The media has devoted significant attention to anecdotes of individuals who post messages on Facebook prior to suicide. However, it is unclear to what extent social media is perceived as a source of help or how it compares to other sources of potential support for mental health problems. This study aimed to evaluate the degree to which military veterans with depression use social media for help-seeking in comparison to other more traditional sources of help.
Cross-sectional self-report survey of adult military veterans with probable major depression. Help-seeking intentions were measured with a modified General Help-Seeking Questionnaire. Facebook users and nonusers were compared via t tests, Chi-square, and mixed effects regression models. Associations between types of help-seeking were examined using mixed effects models. Mean overall help-seeking intentions were similar between Facebook users and nonusers, even after adjustment for potential confounders.
Facebook users were very unlikely to turn to Facebook as a venue for support when experiencing either emotional problems or suicidal thoughts. Compared to help-seeking intentions for Facebook, help-seeking intentions for formal eg, psychologists , informal eg, friends , or phone helpline sources of support were significantly higher. Results did not substantially change when examining users of other social media, women, or younger adults.
In its current form, the social media platform Facebook is not seen as a venue to seek help for emotional problems or suicidality among veterans with major depression in the United States.
As of , there were 1. All told, an estimated 1 out of every 7 minutes spent online is spent on Facebook [ 4 ]. In , Facebook reported that 4 million of its users were US active duty members or military veterans [ 5 ], and a online survey on personal technology use among military service members found that more than three-quarters of them used social networking sites, predominantly Facebook [ 6 ].
However, there are also ways Facebook appears to be used that may be relevant to obtaining emotional support or help for mental health concerns. Among veterans, US Department of Veteran Affairs VA patients appear to use social media to find others with similar health problems at about the same rate as nonveterans [ 8 ].
Social media may be a valuable venue for help-seeking for several reasons. It is a highly accessible resource, and use of internet-based sources of help for health issues is common [ 9 ].
Researchers have been interested in the potential to use social media to reach, recruit, identify, engage, support, or treat individuals at risk for mental health problems [ 10 - 15 ]. Individuals coping with mental illness are active on social media [ 16 ], and Facebook is used as a place to share feelings [ 17 ] and mobilize social support [ 18 ], particularly advice and practical help [ 19 ].
Occasionally, it is even used as a forum to disclose suicidal thoughts [ 20 ]. Facebook, for its part, has collaborated with suicide prevention organizations to develop tools to identify and intervene on behalf of individuals who appear to be at risk for self-harm or suicide [ 21 ]. The importance of novel approaches to enhance help-seeking is accentuated by the fact that rates of help-seeking are generally low in proportion to the number of people suffering from psychiatric problems such as depression [ 22 ] and even recent suicidal ideation [ 23 ].
A similar pattern is seen among military service members and veterans, who are also thought to underuse mental health services or be underserved [ 24 - 26 ]. The need to address this gap between suffering and help-seeking is likely to grow given evidence of rising suicide rates and the list-topping proportion of the global burden of disease attributable to mental illnesses [ 27 , 28 ].
However, it is unclear to what extent social media actually serves as an existing source of help-seeking, particularly for mental health problems and particularly beyond the adolescent and young adult population [ 29 , 30 ]. Thus, the aim of this study was to evaluate the degree to which veterans with depression use social media for help-seeking in comparison to other more traditional sources of help.
We drew participants from a larger study of primary care patients at a VA hospital and its satellite clinics who had symptoms of major depression and reported having at least one close relationship. Patients were excluded if they had severe hearing impairment or recently active major psychiatric comorbidities bipolar disorder, psychosis, or neurocognitive disorder. Due to the low percentage of women veterans, we oversampled women to increase diversity of our sample.
Potentially eligible veterans were first screened for depression via a phone-administered 8-item Patient Health Questionnaire PHQ-8 followed by an in-person visit if eligible and interested. Meta-analyses have found that a cutoff score of 9 on the PHQ-9 is one of the optimal choices for diagnosing major depression in primary care settings [ 31 ]; the identical cutpoint should be used on the PHQ-8 due to its high level of correlation with PHQ-9 score [ 32 ].
We administered the General Help-Seeking Questionnaire GHSQ , an adaptable self-report measure that assesses intention to seek help if experiencing an emotional problem or suicidal thoughts. Because original items were developed in Australia, we slightly modified them for an American context and added Facebook as another potential source of help.
Participants were asked about help-seeking on Facebook generally, without specifying particular areas or functions within Facebook eg, support groups or interest pages.
For categories with multiple items, we averaged participant responses to each source. The GHSQ has strong reliability and validity [ 33 ], particularly when used in multi-item form as we did [ 34 ]. We used a series of survey items adapted from questions used by the Pew Research Center [ 35 , 36 ] to assess social media use.
Next, we assessed frequency of use of the same social media platforms. Finally, we assessed frequency of active social media use sharing, posting, or commenting because prior research has indicated that social media use is often characterized by passive consumption of information eg, scrolling through news feeds , a behavior linked to worsened emotional well-being [ 37 ].
We assessed additional sociodemographic and clinical characteristics including age, gender, minority status, education level, rurality of residence, stability of housing, financial hardship, history of suicide attempt, alcohol misuse, posttraumatic stress disorder symptoms, depression symptoms, and offline social contact. See Multimedia Appendix 1 for additional details. We used mean imputation for missing responses to GHSQ items that were part of informal or formal help-seeking. We summarized key variables using descriptive statistics.
We analyzed sociodemographic and clinical characteristics of participants who were Facebook users and nonusers using 2-sample t tests and Pearson Chi-square tests. To compare help-seeking intentions from different GHSQ source categories, we used multilevel mixed-effects linear regressions.
We performed subgroup analyses to determine whether the pattern of help-seeking intentions differed when the sample was restricted to various groups of participants, including frequent Facebook users defined as visiting at least daily , active Facebook users defined as sharing, posting, or commenting on Facebook at least daily , and users of social media platforms other than Facebook. Analyses were performed using Stata versions In terms of help-seeking intentions, If having suicidal thoughts, Of our participants, Compared to nonusers, Facebook users were younger and used other social media and more likely to be women, live in urban areas, and be at risk for misusing alcohol; they were less likely to have a history of a suicide attempt Table 1.
However, mean help-seeking intentions for each source of help did not differ significantly between Facebook users and nonusers. This was true for both help-seeking for emotional problems and suicidal thoughts. Results also remained consistent after adjustment for potential confounders age, gender, urbanicity, alcohol use, use of social media sites other than Facebook, and history of suicide attempt. All remaining results are based on data from only participants who were Facebook users.
A total of The mean help-seeking intention for emotional problems via Facebook was 1. Help-seeking intention for suicidal thoughts via Facebook was similarly low mean 1. As shown in Figure 3 , comparisons of help-seeking intentions through Facebook versus other potential means of help formal, informal, or phone helpline revealed highly significant differences, with veterans being less likely to seek help from Facebook than from any other source.
This was true for help-seeking for both emotional problems and suicidal thoughts. For example, the mean level of help-seeking intentions via a phone helpline was significantly higher for both emotional problems 2.
In addition, the mean level of help-seeking intentions was highest for formal sources for both emotional problems 4. Detailed data on comparisons of different help-seeking sources is contained in Multimedia Appendix 1. Active Facebook users did show a small but significant 0. In examination of demographic groups of interest, results were again consistent with the overall sample.
These individuals had somewhat higher levels of help-seeking intentions more generally. Their mean help-seeking intentions using formal, informal, and phone sources for either emotional problems or suicidal thoughts was 4.
The primary finding from this study is that social media appears to be a very undesirable venue for mental health help-seeking for VA patients with probable major depression. This finding remained true even among the most frequent users of Facebook and among individuals who used Facebook in an active way which is more associated with positive mental health than passive use [ 38 ].
Findings were also consistent whether the reason for help-seeking was a more mild emotional concern or something much more severe suicidal thoughts. The lack of interest in Facebook for help-seeking is all the more striking when compared to higher levels of interest in offline sources of help.
The majority of our military veterans endorsed at least one venue they were likely to use for help-seeking. This study does not reveal why individuals do not intend to seek help from Facebook. However, we suspect several possible reasons for the large discrepancy in the likelihood of informal help-seeking via Facebook versus offline sources. Prior empirical work has shown that only a small segment of Facebook friends are actually close, personal social connections [ 41 ].
It is this small group that is most likely to influence behavior in the real world [ 41 ]. Second, it may be stigmatizing to self-disclose mental health problems on Facebook. People have a strong tendency to present a positive self-image on Facebook [ 42 ], and stigma is a major barrier to help-seeking that occurs disproportionately among military veterans [ 43 ].
Third, interactions on Facebook are likely perceived as being more impersonal and lacking a human touch. Fourth, participants may not have perceived Facebook as a trustworthy platform in which to openly discuss mental health matters. Concerns about privacy might stifle mental health help-seeking, and some research has suggested trust in social media is low in the United States and acts as a predictor of whether one engages in self-disclosure of health issues online [ 45 ].
There are areas within Facebook that are less susceptible to concerns related to impersonal communication and anonymity. For example, closed support groups, including ones tailored to veterans, would likely be more socially acceptable forums within Facebook for help-seeking or exchange of social support [ 46 ].
Last, because many of the most common reasons for using Facebook are unrelated to health concerns, it may be that, for military veterans, Facebook simply does not come to mind as a help-seeking tool.
In addition, help-seeking intentions via Facebook may be more favorable in individuals younger than our sample population, such as millennials who have grown up with Web 2. Prior research has even shown that adolescents may disclose more personal information on social media than in person [ 48 ]. It is also encouraging that when individuals do self-disclose negative emotions on Facebook, they often receive objective social support, even more so if the person is depressed [ 49 ].
Researchers are also developing tools to help detect risk for suicide based on content of social media posts, which could in theory lead to ways to reach out to individuals online even if they do not actively seek out help themselves [ 50 ]. The primary limitation of this study is the lack of measurement of actual help-seeking or treatment utilization, given that research has found stated intentions of help-seeking may not translate into actual help-seeking behaviors [ 51 ].
Likewise, we were unable to capture whether veterans ever posted on Facebook in the act of help-seeking. Although emotional problems and even suicidality were relatively common in our sample, results must be interpreted cautiously as our survey queried intentions to seek help in a hypothetical scenario.
Additionally, survey order effects could have influenced results such that individuals underreported Facebook help-seeking intentions. Because the item on Facebook help-seeking intentions was placed after items on other sources of help such as friends and family, respondents may have perceived Facebook as being mutually exclusive from these options. Finally, results are not likely generalizable to other populations not well represented in our sample of military veterans, including veterans who lack any social supports, women, or youth.
Our results should not be interpreted as negating the relevance of tools, such as one recently rolled out by Facebook [ 28 ], to assist individuals actively experiencing suicidal ideation. Rather, we believe our results frame the utility of such tools as being best suited to the select few who both experience suicidality and are comfortable using Facebook in a crisis.
Overall, this study suggests Facebook in its current form is by no means perceived as a go-to source for mental health help-seeking among veterans with depression.
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