So, today we're going to talk to you about American Idols, the role of influencers in shaping the public's understanding and utilization of mental health care. With me is Dr. Anna Russell, a general psychiatrist, Dr. Keelan O'Connell, a CAP psychiatrist, and I'm Dr. Cecily Lehman, a forensic psychiatry fellow. And as we were putting this presentation together, we thought about starting with a joke to lighten the moon, like a CAP psychiatrist, a forensic psychiatrist, and a general psychiatrist walk into a bar. But just like our diagnoses, we couldn't agree on a punchline. But in all seriousness, thank you guys for joining us today on what is probably one of the more beautiful days we've had here in San Diego, and late in the afternoon. San Francisco, goodness. So we have, the opinions in the presentation you're going to see today are ours and ours alone. They don't represent the opinions of any of the organizations we're affiliated with. None of us have any relevant financial relationships to disclose. So before we jump into the presentation, I'm going to ask for a little bit of audience interaction. How many individuals have a social media presence? Thank you. I have a Facebook account that I don't interact with much, but when I do, I have to admit it eats up more time than I'd like it to. How many participants in the audience ask their patients about their social media presence? I see some hands. I do on occasion, but I have to admit it's not something that I do regularly or consistently. And then finally, how many people who do ask their patients about social media, ask their patients specifically who they're interacting with or following on social media? Okay, so one or two. Great. So this is a copy of our abstract, and I'm not going to go through the whole thing, but I want to highlight one line. Love it or hate it, celebrities and influencers are leading the discourse on mental health through their various social media platforms and have become the voice of mental health. So with our presentation, we hope to dive deeper into that idea today. The objectives of the presentation are to identify how technological advances have positively and negatively influenced communication about mental health, describe the impact that influencers have on the public's perceptions of mental health and the utilization of mental health treatments and services, and to provide an example of a structured social media-focused mental health evaluation that can be incorporated into your current patient interview. We hope to meet these objectives by first starting with kind of a comprehensive overview of the technological advances in social media and defining some of the terms we're going to use today to make sure we're all on the same page. Then we're going to go on and Dr. O'Connell is going to talk about influencers' role in perceptions and utilization of mental health. Finally, Dr. Russell will talk about the social media interview we've developed, and I think a lot of you got a handout on the way in, but if you didn't, there's some up here in the front that describes kind of our acronym for the social media interview. After she discusses that, we'd like you guys to break into small groups, very, very low pressure, and just talk about some things that you think might work for you or have worked for you in the past with patients, or questions that you could use in the future, and to kind of just practice some of these questions to get used to them. We'll then come back together as a big group and offer some time for question and answer. So I'm going to start out by talking about technological advances in social media. The first thing I want to do is offer a very brief and truncated history of the Internet. In 1989, the World Wide Web begins, and AOL launches Instant Messenger, which is basically just an application that people can use to almost text each other or communicate online. In 1995, there are 18 million American homes online, and at that time, there were roughly three people per household in America. In 1999, the peer-to-peer file sharing application Napster was launched. This was used mainly to pirate music and other media files. In 2000, 43% of Internet users say that they would miss going online, quote-unquote, a lot if it was taken away from them. In 2011, Rebecca Black's Friday video receives over 180 million views. Now I want to stop here and give some context about who Rebecca Black is and what the Friday video was. So in 2011, Rebecca Black was a 13-year-old girl who wanted to be a pop singer. So she wrote this catchy song and created a music video for the song entitled Friday and put it out online. And pretty quickly, it went viral. At the time when she reached over 100 million views, it was one of 43 videos on YouTube that had had that many views. So this really highlights the duality of the Internet because on one hand, she became popular, she became very well-known, but because of her success and the popularity of this music video, she also started to receive death threats. People told her that she should kill herself, that this was a terrible music video, that if she didn't take it down, they were going to find her and kill her. And these threats got to the point where actually the California police had to get involved. Now today, Rebecca Black still has a presence online and she has been very open about her experience with depression since that incident occurred. In 2018, we see that over 75% of U.S. households had either a desktop or a laptop computer. And although I don't have the current information, I would imagine that since COVID really forced us as a society to become more virtual, that this number has likely gone up. So let's talk specifically about what is social media as an aspect of the Internet. And it's defined as communications on the Internet through which users share information, ideas, personal messages, and other content. Some examples of social media platforms are Instagram, Twitter, Facebook, YouTube, and TikTok. Now Instagram describes itself as a simple, fun, and creative way to capture, edit, and share photos, videos, and messages with friends and family. Twitter's tagline is, it's what's happening. From breaking news and entertainment to sports and politics, get the full story with all the live commentary. Facebook describes itself as a platform where you can connect with friends, family, and other people you know, share photos and videos, and send messages and get updates. YouTube describes itself as a platform where you can enjoy the videos and music that you love, upload original content, and share it with friends, family, and the world. And finally, the tagline for TikTok is, trends start here. On a device or on the web, viewers can watch and discover millions of personalized short videos. So let's just take a brief look at the history of social media. In 2004, Facebook was launched. Two years later, Twitter was launched. In 2007, Apple releases the first iPhone. In 2010, we see that 35% of adults have cell phones with applications. Also in 2010, we see that Instagram is launched. In 2012, eight years after its launch, Facebook reaches 1 billion monthly active users and buys Instagram. In 2013, 56% of Americans own a smartphone. So let's look at more current data. This is from 2021. Now 85% of adults, 18 and older, say that they own a smartphone. And we can see that that breaks out pretty evenly between men and women. But where we start to see differences is in the age groups of the adults that own a smartphone. Age 18 to 29, 96% of individuals own a smartphone with applications. Whereas in more mature adults, 65 and older, only 61% of them own a smartphone. Some other statistics for you. The average American spends roughly five and a half hours on their mobile device each day. Americans check their phone on average 96 times per day or once every 10 minutes. And as of 2021, 90% of mobile time is spent using applications. But let's look more specifically at social media sites, not just applications in general. This is a graph of the percentage of the adults who use at least one social media site. And as you can see, the line on top is the younger adults, ages 18 to 29, who are still most of the users. But what is interesting when you look at this, in the last couple of years or when the data collection ended in 2021, there was started to see a decline in adults 18 to 29 who were using social media. But there's been a steady increase in older adults, 50 and up, getting on social media sites and application. What I found interesting about this is when I think about my patient population and who I need to be screening for social media use, I always assumed it would be younger adults and adolescents. But really what this shows us is that people across the lifespan are engaging with social media applications. But what about teens? So nearly all U.S. teens, ages 13 to 17, say they have access to a smartphone. And 45% say they are almost constantly on the Internet. 44% of teens often check their phone as soon as they wake up in the morning. Roughly 58% of teens often sometimes feel as if they have to respond to messages from other people immediately. And about 30% of teens often or sometimes lose focus in class because they're checking their cell phone. So if we kind of look at the aggregation of this data, it shows us that everyone is engaging with their phone. And most people have at least one social media platform on their phone, if not more. Excuse me. So let's talk about who they might be engaging with when they're on these social media platforms and what exactly an influencer is. Miriam Webster defines influencer as a person who inspires or guides the actions of others. Specifically a person who is able to generate interest in something by posting about it on social media. Forbes goes on to describe social media influencers as people who have large audiences of followers on their social media accounts and then they leverage this to influence or persuade this following to buy certain products or services. These social media influencers have established a significant amount of online credibility in their field or industry. So their followers often feel their endorsements are particularly authentic and trustworthy. Now this is such a booming field that Grand Canyon University in Phoenix, Arizona actually offers a BA in social media. So you too can become a social influencer in case psychiatry doesn't work out. They describe a social media influencer as someone who holds a position of authority or credibility. Someone who actively posts engaging, entertaining and or informative content. Someone who has attracted a fairly sizable following of fans on social media. And finally someone who can leverage their authority to influence their followers purchasing decisions. What I want to highlight here is that in all of these definitions, even though the influencer creates this air of authority and uses that authority to influence their followers' opinions on certain services or products, the influencer's opinions may not be based in any sort of actual knowledge or scientific information. They've just created this persona that followers feel comfortable with and feel like they can trust. For example, a celebrity or influencer may encourage their followers to purchase something like crystals to cure their mental illness or mental health. And that's not based necessarily in any knowledge about mental health and may come from an ignorant point of view, but the followers may not know that or realize that because they have this faith in the influencer and feel like the influencer is credible in this subject matter. Now not all influencers are created equally. There are tiers of influencers with the top tier being mega influencers who have over 1 million followers on a certain platform. You can see as the inverse pyramid kind of gets down to the point, you have the nano influencer who has 1,000 to 5,000 followers. Most individuals or influencers fall in the micro influencer range with 5,000 to 50,000 followers. Now why do we care? Why is this important? Well, this is kind of the wave of the future. This is a growing industry and more and more of our patients are going to come in with some sort of preconceived opinions or notions. Last year alone, $16.4 billion was spent in the influencer marketing in the global market. So this is something that regardless if you yourself are a social media user, likely the chance is that your patient is. So who are these people? Who are these influencers we keep talking about? We're looking at data collected in January of 2023 across Instagram, Facebook, and Twitter. Here are the top five influencers. Number one is Portuguese soccer player Cristiano Ronaldo with 787 million followers. Following him is Leo Messi, an Argentinian soccer player with 530 followers. Third is Selena Gomez, an American actor and musician with 499 million followers. Justin Bieber, a Canadian musician with 477 million followers. And Kylie Jenner, an American influencer, reality TV star, and businesswoman with 450 million followers. Now if we just look at these numbers and assume that there's not a lot of cross-following on different platforms or between these celebrities or influencers, these five people alone, when they post something, have the opportunity to influence over 2 billion people, which is pretty huge. And of the five individuals on the screen, the last three, Selena Gomez, Justin Bieber, and Kylie Jenner, have all been public about their own personal struggles with mental health. So how are we doing in comparison? Well the American Psychiatric Association, when we look at Twitter alone, we have about 3,000 followers, so, you know, a nano-influencer, but we're still out there. And when we look at the National Alliance on Mental Illness, they have a little more than half of what the APA has, 1,876 followers. Oh, I'm sorry, you're right, I'm sorry. So still 1,000, oh goodness, thank you so much for correcting that. So much better than that, but still not quite in the millions like the mega-influencers. Thank you for that correction. So APA has 169,000 followers, and NAMI has 191,000 followers, 0.9 thousand followers. So we're still not hitting quite the mega-influencer range, and again, why do we care about this? Well in the military we have a term called force multiplier, and this is anything that multiplies our efforts, because we don't have enough psychiatrists to be everywhere that we need to be in the military. So we use behavioral health techs and other people to help spread our message and help decrease stigma about mental health, and I think that's a good way to look at and understand these influencers online, that they can be a force multiplier and put out a good message of mental health, or looking at the opposite, they can put out a negative image of mental health, which may influence the patients that we see and change our therapeutic alliance for the better or worse. And I want to leave you with two examples. The first, the positive influence that we can have, that influencers can have. With Cristiano Ronaldo, again looking just at Twitter, he has 108.2 million followers, and on World Mental Health Day he posted this, advocating for his followers to join him and basically showing his support, sending out a message that it's okay to get mental health and working together we can get stronger. Which if your patient is a follower of Cristiano Ronaldo, may come in with an open mind and it may be easier to build therapeutic alliance with that individual. On the other hand, if you look at someone like Elon Musk, who has 133.5 million followers, when he puts out a tweet like this, well, Buterin is way worse than Adderall in my opinion. It should be taken off the market. Every time that drug has come up in conversation, someone at the table has a suicide or near suicide story. If that's the influence that your patient is having, they may come into you with already preconceived notions about certain medications or be hesitant to engage with you to begin with. So that's why it's important for us to know what kind of influences our patients are having. Thank you for your time. I'm going to turn it over to Dr. O'Connell, who will go further into that idea. Hi, everyone. Thank you so much for joining us. I know it's late afternoon, the last session of the day, energy might be waning a little bit. If you need to get up, stand up, move around, please feel free to do so, but we're glad to have you here. I do have a confession that I want to make at the outset. I can think of at least one time in my life when I have been under the influence of a celebrity. There may be more times than that, but the one that comes to mind was just last week. I was dropping my kids off at daycare. I saw another parent who looked remarkably like Ed Sheeran, one of my favorite singers. I knew it wasn't Ed Sheeran, but my heart still skipped a beat, and I had this urge to run over and ask for his autograph. I was able to maintain my composure, texted my friends about my near-celebrity sighting and went on my way. But I realized that maybe I have a lot more in common with my child and adolescent patients than I realized. I know that I've experienced them being influenced in their thoughts and actions by influencers, and I guess I'm not immune to that either. So before I get started, I just wanted to clarify a couple things. I'll be using the words celebrity and influencer interchangeably, and then I'll be using the concept of us or layperson or commoner or society to mean anyone who's really not an influencer or society. So with that, I'll jump into my part of the presentation, the mechanisms behind the influence of celebrities in our society and their role and how the lay public perceives and utilizes mental health. So I'd like to start off by showing this commercial. It aired in the United States a couple years ago. You might be familiar with it. Again, I'm not here to make any endorsements or denounce any celebrities or products or companies, but we'll watch the video and then kind of briefly discuss it afterwards. We are the TV doctors of America, and we're partnering with Cigna to help save lives by getting you to a real doctor for an annual checkup. So go, know, and take control of your health. Dr. Posesh. Okay, so the rhetorical question that I posed to all of you after watching that, just something to mull over as we go over the next few slides, is why is the general public more influenced by celebrity doctors than by actual recommendations made by health professionals? So let's delve into that. Why are we influenced by celebrities? There are many different theories from different fields of study, and I'll highlight a few of the more pertinent ones here. The first one is the idea of parasocial relationships. That's a one-sided relationship between a celebrity and a layperson like ourselves. And in this relationship, the layperson perceives themselves to have a strong interpersonal and emotional connection with the celebrity. So a good example, I think, of this is that it certainly applies to my own life. I like to watch the news, local and global news, or national news, in the morning and the evening when I'm getting ready or I'm cooking dinner. And I come to know the local news anchors and weathermen, and I trust them to deliver the news. I come to expect, anticipate, and laugh at their corny jokes. And if they're not on the air on any given night, I kind of miss them. So even though they don't know who I am, we've never met, I have a parasocial relationship with them because I feel like I know them in a way. So research has demonstrated that if we can find similarities or some type of relatedness with celebrities, this can help to decrease stigma, especially if they disclose a mental health condition. Conversely, if we feel that a celebrity is just too dissimilar from us, kind of on a pedestal, too protected from the problems of everyday life, that has a more muted effect on changing stigma. The second idea I have here is signaling theory. And it just basically says, with so many choices out there, we face hundreds, even thousands of choices every day, it can be hard to make good, informed decisions. So we have the natural tendency to look to others to help us make informed, credible decisions. I think a good example of this is, if you're not a cereal eater, and you decide you're going to start eating cereal, you go to the grocery store, you walk down the cereal aisle, and you're inundated with hundreds of choices for cereals. I mean, how do you know which one to choose? Your eyes might fixate on the Wheaties box, you see an athlete on there, maybe Michael Phelps, and subconsciously, you might think, hmm, well, if the cereal is good enough for him, maybe it's good enough for me, too. Or I want to look like him, I want to be a successful athlete like him, I guess I'll choose Wheaties. So that's one example. Actually, Captain Crunch is a strong motivating reason for why I joined the Navy. I'm just kidding. But yeah, so akin to that is the idea of herd behavior in economics. This says that people have a natural tendency to look to others who have been in a similar situation when they're facing a major decision or situation. That can be for a number of different reasons, including knowing that there's safety in numbers, seeing that somebody has achieved what we want, so they have a roadmap for us to follow. Also, it just doesn't take a lot of mental energy or effort. So what comes to mind with this, for me at least, is all the celebrities who endorse different diets or weight loss pills. It's very common for society to want to look like celebrities, so it makes a lot of sense. Finally, halo effect. I think a good example of that is from the video or the commercial that we watched. This is the idea that success in one area, like acting, translates to success in an unrelated area, like giving medical advice. So if you identify with Noah Wiley or Patrick Dempsey or any of the other doctors on the commercial, you might think, hmm, that actor is credible, upstanding, and successful. Therefore, their medical advice must also be credible, upstanding, and successful. So these celebrities are often perceived to have greater credibility than their non-celebrity counterparts, even though we know they have less medical knowledge and experience. And that certainly harkens back to what Dr. Lehman was speaking about. Now our understanding of the mechanisms behind the neuroscience of celebrity influence is constantly evolving. Research has shown that when an object is paired with a celebrity's face, the areas on the left side of the slide, those areas of the brain light up. And if we have positive associations or positive memories associated with the actor or the influencer, those are then translated to the product that is being sold or endorsed. So here we see a picture of Zendaya, and she's selling bracelets. If we think of Zendaya as someone who's beautiful and wholesome, then those same qualities will be ascribed to the bracelets. They'll be seen as beautiful and wholesome. Interestingly, our brain really isn't very good at differentiating between trustworthy people we know in real life, maybe like our mom, our families, coworkers, and influencers, or people we only know through social media. The more familiar they are, the more the brain becomes active, even if we've never actually met the person. I'd like to transition and talk about the negative and positive aspects of social media, as well as some specific examples of influence of both. I want to start with the negatives so I can end on a high note with the positives. I don't think there's anything on this slide that's too earth-shattering. I think we're all aware that heavy social media use can increase the risk for mental health disorders and suicidal ideation. Social media may promote negative experiences, such as the ones listed here, including the fear of missing out or an unhealthy self-centeredness and feeling like everybody's watching you, judging you, you're never good enough. When we talk about the negative impact of celebrity influence, the contagion effect certainly comes into play. The contagion effect suggests that highly publicized suicides increase the rates of suicide among vulnerable individuals in the days, weeks, and months following the publicized suicide locally, nationally, and even globally. Marilyn Monroe is considered the quintessential copycat suicide effect. After her suicide in August of 1962, the U.S. reported an increase in suicide rates by 12 percent, or an additional 303 suicides in that month. A more recent example is Robin Williams, who died by suicide in August of 2014. We have a little more clear data on rates after that, so the increase in suicides went from 113 per day in August of 2012 and 2013 to 142 per day in August of 2014. And the majority of these suicides were with the identical method that Williams used. Encouragingly, while there were an uptick in suicides, there was also an increase in help-seeking behavior, because the National Suicide Prevention Lifeline and the Suicide Prevention website increased pretty dramatically, as you can see here. So now let's talk about some specific examples of celebrities and their negative influence on us as individuals and as society as a whole. So with that, I bring up the Kardashian family. They have been dubbed by many to be America's favorite family. They have their own reality show that's run for 20 seasons. And among other things, they're known for their picture-perfect bodies and pouty lips. They have been essential in promoting the slim, thick body ideal, which is a flat stomach, an impossibly thin waist, a large derriere, and toned thighs. The Kylie Lip Challenge was a short-lived 2015 social media phenomenon in which teens and pre-teens would put their lips in a shot glass to create suction to cause their lips to swell to approximate Kylie's pout. These celebrities have made a small fortune by promoting some of the health and nutrition products listed here, all the while adamantly and repeatedly denying ever having had any plastic or cosmetic surgery. I'm not here to debate whether they have or haven't, but a lot of people have called into play how they could achieve their picture-perfect bodies with just these supplements alone. And one fan had wrote on Twitter that the Kardashians do owe it to us to disclose if they've had any cosmetic procedures done, because they said, we're not stupid, we deserve to know, they've pushed these body types on us, and so it's only fair that they are held accountable. Okay. So moving over to the positive impact of celebrity influence, a little lighter topic. We know that celebrities are professional storytellers, which is a trait that's valued in cultures around the world. It helps to make stories and experiences more tangible and more relatable. Celebrities are also great social models. We're able to see in real time how their disclosure of a mental health condition affects or impacts their career. And so if a celebrity discloses having a mental health condition and then continues to work, be successful, be popular, make money, that might influence us to reach out for help as well or perhaps to share a diagnosis with someone else. So celebrities can certainly use their voice to serve as advocates to decrease stereotypes and stigma in our society. And I would argue this is especially important in underrepresented populations in mental health in our society, which include males and African Americans. And this can be for a number of different reasons, but would include distrust in the medical system, poor quality of care due to racial biases in healthcare providers, and a lack of racial and ethnic diversity among mental health providers. So down here I have a quote from or a tweet from Harry Styles. He is a British singer who got his start on One Direction, in the band One Direction. Now he's a solo artist, just won the 2023 Grammy for Best Pop Album of the Year and Best Album of the Year. He has been very vocal about inclusivity for people of all genders, orientations, and identities. And recently he's really spoken out about the importance of therapy. He used to say, I wanted to prove that I didn't need therapy, but when I went, I found that it made me a lot happier. And now I recommend it to everybody, because if it can make you even 1% happier, then it's totally worth it. So here he's writing to a fan and he says, go to therapy. It's important. I'll wait for you. On the next couple of slides, I have a couple of different examples of celebrities. And I tried to arrange it sort of like a baseball card, where I list kind of the most pertinent facts about the celebrities in relation to this discussion. So I apologize if I left something out that you may know about the celebrity and find interesting. There certainly is a lot of interesting information on these people. But I start off with Dwayne the Rock Johnson. He has 366 million Instagram followers. He's a former professional wrestler and turned actor. And he has a background of being half black and half Samoan. He has self-disclosed having multiple episodes of major depressive disorder throughout his life, major depressive episodes. And I would like to explain that when I list the diagnoses up here, these are all self-disclosed by the celebrity or the influencer. It's not me taking a guess at what it might be. So I included the Rock, because not only is he a successful actor, he happens to be a black male. So he's in the unique position to be able to reach out to the underrepresented minority in our culture to hopefully speak to them and help them and encourage them to seek mental health help. So this tweet is from 2018. He says, we all go through the sludge, and depression never discriminates. It took me a long time to realize it, but the key is not to be afraid to open up. Especially us dudes have a tendency to keep it in. You are not alone. Next, I have Demi Lovato. She is an American singer and actress. She got her start on the Barney Show and now has gone on to do bigger, greater things. She has an interesting background, as you can see, and multiple diagnoses, including being gender fluid. I mention that because she says she is a proud member of the Alphabet Mafia and is a big advocate for LGBTQIA plus rights. She also recently released the documentary Dancing with the Devil, which outlines her struggles with substance use and the overdose that almost killed her. Michael Phelps, arguably the greatest swimmer of all time, definitely the most decorated Olympian of all time with 28 medals. He reports having ADHD. He's had issues with substances in the past and major depressive disorder. And if you've watched any TV in the past five years or so, you've probably seen one of his commercials where he is a spokesperson for the online psychotherapy platform Talkspace. Sabrina Williams, also arguably one of the greatest tennis players of all time. She was diagnosed with postpartum depression after the birth of her daughter in 2018. She had complications from birth, including a pulmonary embolism that left her bedbound for six weeks. She often writes on Twitter or Instagram about feeling in a funk and having trouble balancing work, family, and mom responsibilities. And she encourages others that you're not alone. We can get through this together. And Jonah Hill, interestingly, he deleted his Instagram and all social media that I'm aware of due to self-reported panic attacks. So he could be a great role model. If you notice that a patient of yours is maybe heading down the wrong path, is having a really negative experience with social media, could maybe benefit from a break. He might be a good person to bring up. He's been in many notable movies over the past couple decades. And he produced this documentary, which is about his own psychotherapist, who's also a psychiatrist. And he brings a camera into some of his own therapy sessions to help to kind of remove or peel back the curtain, try to eliminate some of the fear surrounding going to therapy or the mystery of going to therapy. All right. And then we have Megan Thee Stallion. She is an American rapper born and raised in Texas. She rose to fame via social media. And as stated, her goal is to be the rap version of Beyonce. She's had multiple life stressors, including being the victim of a shooting and the deaths of several close family members in short succession. She has a website, the name of which is listed here, that lists resource directories for underrepresented communities in mental health, including Therapy for Black Girls and Black Men, LGTVQIA+, and Psychotherapists of Color. The website also has therapy platforms, text lines, and podcast recommendations. Finally, mental health permeates politics. This is a picture of Senator Federman. He was hospitalized in March of this year for suicidal ideation and depression. Certainly, politicians at all levels, as well as presidents and first ladies, have advocated for mental health awareness and reform, but we still have a long way to go. But it's important to remember that politicians are not immune to experiencing mental health problems. And with that, I will turn it over to Dr. Russell. This presentation has reviewed the technological advances and the influencers' impact on the public's perception of mental health, and now we will discuss the social media interview. So what is a social media interview? It's a guide that we created on how to evaluate the role of social media usage in our patients. There is not a standardized guideline on how to assess the role of social media in patients' behavioral health. While we were looking for one, we found recommendations from the American Psychological Association and the American Academy of Pediatrics. So the American Psychological Association recommends for adolescent social media use that adolescents be trained in social media literacy to ensure they have skills to maximize the chances for balanced, safe, and meaningful experiences. The American Academy of Pediatrics recommendations ask providers to ask two social media-related questions in addition to obtaining a thorough history. How much recreational screen time is consumed daily, and is there a TV set or an internet-connected electronic device in the patient's bedroom? In our review of the literature, there is an approach to the psychiatric assessment of adolescent social media use, but there is not a standardized guideline or a review for adolescent social media use, but there is not a standardized guideline or recommendation for adults. Suggestions for performing this evaluation have included utilizing the DSM 5th edition cultural formulation. It can be used as a practical interview guide that can help formulate the media-related context of illness experience. And other research suggests utilizing the Minnesota Impulsive Disorder Inventory to model questions about social media use. So why is this important? In addition to everything we've talked about so far today, in 2019, the American Psychiatric Association released the results of a national poll that showed that more than one in three adults see social media usage as harmful to mental health, and only 5% saw it as having a positive impact. The rest reported mixed views. Social media is becoming integrated into the fabric of human connection and should be evaluated. This assessment could improve harm reduction, strengthen treatment plans, and build therapeutic rapport. When should this topic be introduced in the behavioral health interview? Providers can ask their patients about social media usage at their first encounter and then at regular intervals as indicated. Indicators may include the patient identifying social media use impacting their mood or sleep, identifying a chief concern such as cyberbullying or cyberstalking, or using social media as part of a treatment plan. The frequency of this interview will vary by patient, and these questions should be asked during the social history. How should this interview be conducted? Clinicians should address social media questions with open-ended prompts, be curious and ask questions, openly communicate understanding that online activities can be beneficial, and maintain a non-assuming attitude. After reviewing the research on this topic, common themes and sample questions were identified to create this approach to interviewing a patient about their social media usage. The common themes include the quantity or time a patient spends on social media, activities they view or participate in, the influence of social media on their mental health, and the patient's perspective or experience while using social media. An easy way to remember these topics are to evaluate if your patient needs to tame their social media usage. The lion. Assessment of the time used on social media can start with open-ended questions, such as, tell me about your time on social media. Specific questions may include, how much time do you spend online during the day? And what time of the day are you on social media? There was a systemic review on the relationship between social media and mental health, and it showed that increased social media usage equals lower mental health. So more questions like, has social media use ever made it difficult to complete daily tasks, may encourage disclosure on how their use of social media influences their overall functioning. Questions about the patient's activities on social media may start with, what are the activities you do on there? And can be specified to, what are your favorite social media apps, and tell me about your favorite influencers. The literature shows that the specific impact of social media use seems to be influenced by how individuals engage. So people who post and share content So people who post and share content report increased satisfaction than those who engage more passively. Doom scrolling refers to excessively scrolling through bad news on social media, which is considered to be problematic news consumption. Asking patients what they like about their social media activities may open the door to conversations about why they use social media. Learning how social media use impacts patient's moods or mental health symptoms may enable the provider and patient to gain insight. Establishing the relationship of social media use to the presence and timing of psychiatric symptoms can help determine correlation or even causality. Specific questions may correlate with the psychiatric review of systems, such as, do you use social media? Such as, do you go online before you go to sleep? Can lead to questions about sleep patterns with phone use. Is alcohol use in the content that you view? May lead to questions about their view on alcohol use and how their friends are using it or peers. Pro-ana at the bottom is a slang term that essentially encapsulates positivity towards anorexia and other eating disorders. Pro-ana websites refer to online message boards, communities, blogs, and other resources that encourage disordered eating. Pro-suicide websites refer to online message boards and other resources that share suicide methods and encourage self-harm. Asking patients about their experience on social media enables the provider to learn about the patient's perspective. So some patients identify a positive experience, including creative expression, sense of community, and participating in cultural movements. Sharing their lives through text, pictures, and video may enable relationship building and strengthening of the patient support system. Some patients identify negative experience, including increased loneliness and isolation. Cyberbullying is the willful and repeated harm inflicted through the use of electronic devices. Cyberstalking is the use of the electronic devices to stalk or harass an individual, group, or organization. And doxing is the intentional revelation of a person's private information online without their consent and often with malicious intent. As stated, there is not a standardized guideline on how to evaluate patients' use of social media in the behavioral health assessment. Our goal in identifying these themes and providing example questions is to add an aspect of the patient's life to their behavioral health evaluation without the need for a standardized guideline. The goal is to ensure that the patient's use to their behavioral health evaluation without greatly extending the psychiatric interview. These questions can be used to facilitate a deeper conversation and promote patient's insight into their social media usage. This is a revised model of the biopsychosocial formulation regarding online media use. This can be used to identify the dynamic interaction of biopsychosocial variables and individual patient vulnerabilities. One example from the chart is a predisposing factor or vulnerability that's identified as a predisposition to addictive, disruptive, or compulsive behaviors in the context of social media use. Identifying these factors in your patient assessment can assist in case formulation. What is the healthy dosage of social media use? A meta-analysis was conducted with a systemic review on the relationship between social media and mental health that focused on Facebook, Twitter, and Instagram. The findings are mixed and show that social media can both support and hinder one's mental health, just as previously described. A true sense of community occurs when role models promote awareness and relate to others. Celebrities, policymakers, and athletes tweeting about a mental health issue can have positive results. Studies have shown that young people who spend more than two hours a day on social media are more likely to report psychological distress. And results of these studies are consistent in showing that increased social media usage equals lower mental health. In February this year, the American Psychiatric Association released recommendations on tips for positive social media use for mental wellness. The focus of this post is to accentuate mindful use of social media. If you mindfully use social media, you can cultivate positive habits that prime you for social wellness, enhanced belonging, and potentially strengthen protective factors against mental health disorders. One tip listed is to focus on your real friends and maintaining connections versus voyeurism, which can increase feelings of loneliness and inadequacy. This information is available on the APA's website and can be printed off as a discussion point or education piece for your patient. Another post from the American Psychiatric Association released recommendations on how to cut back on social media use. This brings us back to our thoughts on Jonah Hill's deleting of Instagram to improve his overall mental health. One of the tips I wanted to point out on this is to track your time, which talks about downloading an app and it'll tell you how often you check your phone, what you do on it. So if your patient is interested in this, if you have an iPhone or a Samsung, it's actually under screen time options and you are able to schedule downtime, set app time limits, and set communication limits without downloading another app. So if this is something your patient wants to actively work on and is motivated to change, it's something that could be a easy bullet point in your treatment plan. As previously mentioned, asking about online activities can encourage patients to reflect on their behavior patterns and its impacts. Identifying if patient's behavioral health symptoms worsen in relation to their pattern of online activity is a topic that can be addressed as part of a treatment plan. Patients may need encouragement in utilizing positive habits of social media or identifying offline alternatives to online activities. There are phone applications available to remind patients about aspects of self-care, such as taking medications or exercising. So how can providers feel prepared to discuss social media use with their patients? The research suggests that providers be broadly familiar with the main social media platforms and how they function. It will be helpful to know potentially harmful mental health-related online communities such as the pro-ANA and pro-suicide websites I mentioned earlier. Providers should be able to share their experiences Providers should be open to discuss what is currently popular or trending online. For example, we described TikTok earlier as a social media platform where users create and share videos. During the COVID-19 pandemic, the use of this site greatly expanded as well as the tick and Tourette syndrome content on the website, as well as patients with symptoms of ticks in neurology clinics. One research article compared these TikTok ticks to typical tick disorders and found them to be distinct from typical Tourette syndrome. This is an example that's believed to be called mass sociogenic illness, which involves behaviors, emotions, or conditions spreading spontaneously through a group. It's important to reiterate that having an open mindset and non-judgmental attitude when discussing social media usage with patients may strengthen report building and encourage patient disclosure. A potential condition for further study is problematic internet use. It's also termed as internet addiction, internet dependence, compulsive internet use, and pathologic internet use. It has no broadly accepted definition or diagnostic criteria. It has been associated with depression, social anxiety, substance use disorders, and aggression. Whether problematic internet use should be conceptualized as an impulse control disorder or as an addictive behavior disorder remains controversial. Continued research on this condition will influence the evaluation of social media use and the treatment of our patients. So further work is needed. There needs to be a standardized guideline on how to conduct a social media interview for all ages, recommendations for provider training, recommendations for provider training, more research on problematic internet use, education for social media influencers on their impact in the viewer's behavioral health, and considerations of the liability of social media services. Because of Instagram and the high level of mental health issues it has been associated with within the literature, the Royal Society of Mental Health proposed social media platforms place a warning on images that have been digitally enhanced or altered photos to reduce feelings of inadequacy. They have also recommended that social media platforms create a heavy usage notification to pop up after too much time has been spent online. Social media is not going away, so developing a safe relationship and constructively using social media may not only decrease the negative impact on one's health but may have a positive impact instead. So we've reviewed a lot of information and now we're gonna do a brief low stress small group activity. On the app and around the room there are printed handouts of our TAME worksheet. Just as a reminder, evaluate if your patients need to TAME their social media use by asking about these topics, time, activities, mental health symptoms, and experience. And these are the open-ended questions. So we ask that you grab a partner, make a small group, think about how do you do these evaluations with your own patients, share that with your group, practice a few questions from the worksheet, and in a few minutes, not long, we'll come back and we wanna hear about your experience, about your thoughts on the worksheet, and overall the evaluation. If you don't have the physical worksheet, it's also on the app. I believe it's the first attachment. Start the timer. But yeah, I would be curious to hear kind of what that was like for you, if you've got any insight. Yeah, so no, it was an interesting activity, but my partner and I were discussing how we both feel like there's a lot of interesting pros and cons to the rise of social media, and one of the cons is this huge uprising of the social contagion of certain cool, hip, popular diagnoses. In my clinic, anecdotally, I've seen like a 300% increase in people asking for diagnosis of ADHD because it is so hip, so cool. It makes you like really unique, quirky, and you're not like other girls, and then my partner says the same thing with autism, and it's something that you can put on your profile, give you, but obviously there's positive aspects of it too. It is massively decreasing stigma and barrier of entry into seeking help for mental illness, but it is, I mean, I'm sure most of us know right now there's like a crushing shortage nationwide of ADHD stimulants, and part of the problem is this hashtag ADHD thing. I mean, a lot of my patients will come right out and say it to me that, hey, I saw this TikTok video on ADHD, therefore I really want this diagnosis. Thank you for sharing. I've experienced that a lot in working with children as well. Both of those, the push for a diagnosis for ADHD and autism. Yeah, I think that's a great point because once someone I think gets their mind set on and has those perspectives about a diagnosis, once they come and see you and determine that that's not the actual diagnosis they have, they may be very hesitant or disengage with you because they don't want a less hip or cool diagnosis like anxiety if, oh, but everybody else has ADHD and that's what I want. And it's unfortunate because you may lose that person if they don't choose to follow back up or it can really damage the therapeutic alliance. So thank you for sharing that. Just gonna add on to that comment. I totally agree. I think one of the difficulties with social media and short form content like TikTok, like Twitter is that there is no nuance. There's really no room for that. And psychiatrists and mental health professionals are all about the nuance. So it makes it really hard to have those conversations. And I'm gonna out myself as a TikTok user. But just from your experience, I saw a TikTok on ADHD and it was like, if you experience these five things, you have ADHD. And one of them was like, you walk into a room and forgot why you walked in. That happens to me probably daily. The other one was like, you zone out while you're eating chips and suddenly you've eaten a lot more than you expected. I think that's a normal human experience. But there's this tendency to over pathologize and to seek explanations for one's difficulties, which I think is normal. But again, the nuance makes it difficult. And I think one last thing I was just gonna add was I think the reduction in stigma is real but really pronounced for things like depression, anxiety and less so for severe mental illness. I really don't see as much reduction in stigma anecdotally for things like schizophrenia or bipolar disorder. So thank you. I can say hi, I'm from Denmark. And when I see patients, I have like sort of an idea they do self-harm. I do ask them like, so if you post it anywhere like Instagram or other places, because in Denmark, we got noticed about there's like a private Instagram. So when you do self-harm, you're invited if you do like big self-harm, like cutting, cutting like, I don't know, pulling hair out or anything. And when they do self-harm and they post it online on Instagram, TikTok or anywhere else, they do like infect other people to do more self-harm. And that actually happened to young people and young women ended up dying from it. So that's where I actually end up asking to like, if they post anything online. Thank you for sharing. I have a couple of thoughts too, because in our review of everything, they talk a lot about especially younger people having their Instagram. So they have their Rinsta, which is the real Instagram where they have family members on, maybe people from school and then they have their Finsta where they show more private things, where I would kind of, where the research had shown that's where more of the private self-harm was published or there was also something I read about called a vague booking where people post online to get attention, to cause concern, but not enough to actually show like either blood or harm, things like that. So there's a lot of these things coming up. And as far as, sorry, I lost my train of thought. I was just excited because I read about that. But yes, I think that's something that I came across too in researching is just using social media to sensationalize self-harm and other things and approaching it. I think one of the pictures I saw was just a jar of razor blades taken in a really like beautiful way and talking about, well, isn't this like a great and beautiful thing that you could do or engage in and almost decreasing stigma around it and normalizing it in a not positive, but a negative way. So children, adolescents, young adults feel that everyone is doing it and it's not a bad thing, which is something that I've seen. Thanks, I remembered. It was the pro-suicide websites too. They are something that we should all be aware of. And I didn't learn it from classes. I learned it from patients telling me about it. So if we don't ask, we'll never know. Thank you. Did anyone else have any questions or comments or any feedback for our TAME worksheet? All right, well, thank you all so much for coming and spending your afternoon with us. We appreciate your engagement. If you have any questions, please feel free to come up and speak with us afterwards. And I also wanted to give a very happy birthday shout out to Dr. Lehman here. I just discovered it was her birthday, so. Thank you, have a great day and a great rest of your conference.

mental health

social media

influencers

parasocial relationships

herd behavior

mental health awareness

misinformation

TAME method

patient assessments

clinical settings