Case Scenario

A 25-year-old woman presented to my clinic with some mood issues that she was experiencing. From the moment I greeted her, she was entirely engrossed in her smartphone, rarely taking her eyes off of it. I could see it was the Facebook app that was demanding all of her attention. The patient described feelings of depression and anhedonia, as well as difficulty sleeping and concentrating. When I asked what was going on with her friends on Facebook, she broke down in tears, explaining that several of her friends had recently gotten married, one had a new baby, and some friends were even working abroad. Meanwhile, she had yet to find a fulfilling job, was not in any kind of serious relationship, and could not afford to travel. She was happy for her friends, but was also constantly reminded of the seemingly fabulous lives they were leading every time she looked at social media. She could not help but compare their lives and experiences with her own.

Is social media use something that physicians should discuss with patients, particularly those with mood disorders? If so, will the discussion make a difference?

Commentary

Americans spend more time on Facebook, the world's largest online social network, than any other website.^1,2 On the surface, social media networks provide an “invaluable resource for fulfilling the basic human need for social connection.”¹ However, rather than enhancing well-being by fulfilling communication needs that are deeply human, current research suggests that these online platforms may actually undermine it.¹

Much of the current social media literature has focused on social media use and the fear of missing out, or FOMO, in the millennial age group (typically defined as persons born between 1980 and the early 2000s), although some research suggests that it is not limited solely to millennials.³

IDENTIFICATION

In 2013, the abbreviation FOMO was added to the Oxford dictionary and defined as “anxiety that an exciting or interesting event may currently be happening elsewhere, often aroused by posts seen on a social media website.”⁴ To avoid this feeling of being left out, some persons have an impulse to constantly connect with others through social media, which in turn can make them feel dissatisfied, anxious, and unworthy.² Even when patients are not actually able to name anything in particular that they are missing out on, they may still possess fear that others are having a better time.³ This can lead not only to emotional symptoms, but also to physical symptoms, including shortness of breath, palpitations, headache, sore throat, chest pain, and less mindful attention.^3,5

Social media use is feeding into a sense of relative deprivation, the “dissatisfaction people feel when they compare their positions to others and grasp that they have less,” particularly when they see their peers engaging in enviable experiences.³ One report found that American men are more likely to be affected by this phenomenon.³

HEALTH IMPACT

Recent studies of millennials demonstrate an association between increased social media use and increased rates of depression, anxiety, loneliness, and distracted driving, as well as lower levels of life satisfaction and productivity.^1,6–9 Viewing social media intensifies feelings of irritability, anxiety, and inadequacy.² Additionally, the drive to stay in the loop can contribute to a cycle of unhealthy social media use. The more time individuals spend on social media, the more likely they are to feel that they are missing out on something, which many will then try to alleviate through more social media activity.^4,8 Higher FOMO scores, as measured by a validated 10-question scale, are significantly associated with lower feelings of competence, autonomy, and connectedness with others compared with persons who do not worry about being left out.⁸

In a study of undergraduate students, those who worried more about being left out were more likely to be checking Facebook during class lectures.⁸ More concerning, they were also more likely to be texting or e-mailing while driving.⁸ In fact, using Facebook more often, having more Facebook friends, and doing more impression management on Facebook may predict symptoms of other disorders besides depression and anxiety, including narcissistic, antisocial, obsessive-compulsive, and histrionic personality disorders, as well as bipolar disorder.⁹ Social media use and smartphone use, especially near bedtime, are also tied to lower-quality sleep.¹⁰

In a 2015 public opinion poll, approximately one-half of participants said they could not live without a smartphone.¹¹ When separated from their phones in experimental studies, many participants exhibited symptoms classically associated with withdrawal from addictive substances, including anxiety, increased heart rate, and increased blood pressure.¹¹ Slightly more than one-fourth of persons who responded to a 2013 online survey indicated they would be willing to give up reality television or even cigarettes in exchange for social media access.¹²

MANAGEMENT

In a world of endless status updates, where self-worth is determined by number of likes, what can we offer our patients? Smartphones and social media are not going away, and their use spans generations and cultures.³ Family physicians need accurate and updated information on social media use and available technologies to minimize harmful misuse by our patients, particularly those with mood disorders.¹³

Ironically, there is an app for that (Table 1). Although it may seem inherently contradictory to use technology to limit the use of technology, there are several apps and programs that help limit total social media time per day or restrict use to predefined time windows in the day. Other programs can track the total amount of time spent on social media to make users more aware of their potential for overuse. Family physicians can recommend additional interventions, including changing notification settings to daily or weekly instead of instantly, developing offline relationships, committing to daily personal improvement practices (e.g., yoga, meditation, exercise), and cutting back on the number of social media formats on which the same person is followed. Most importantly, we can help patients change their mindsets and learn to be present in the activities in front of them, not focusing on the ones they feel they are missing. Mindfulness activities and cognitive behavioral therapy may help patients achieve these goals.

APPROPRIATE SOCIAL MEDIA USE IN CHILDREN

Advising parents is also an important part of the family physician's role in discussing social media use. It is key that parents acknowledge the social importance of children's experiences while also setting appropriate limits. Parents should consider non-texting–enabled phones for young children who have phones, and openly monitor their child's or adolescent's digital habits and virtual friends.¹⁴ Creating a family online-use plan can help emphasize safety, privacy, and healthy technology use,¹³ as well as help parents model healthy social media behavior for their children. Ultimately, the best advice for how to approach most things in life applies with social media, too: everything in moderation.

Case Resolution

The physician in the case scenario should discuss with her patient how her social media use may be contributing to her depression. We recommend encouraging a trial of unplugging from or limiting social media use with the help of one of the apps in Table 1; suggesting that the patient change social media notification settings from instant to daily or weekly notifications; discussing selective serotonin reuptake inhibitor treatment options; and coordinating an appointment with a behavioral health team to discuss coping techniques and counseling, if the patient desires. Finally, the patient should have close follow-up to reevaluate her mood and continued social media use.