Mental Health Matters | How much Social Media is too much?
So here you are, gazing into a screen when you could be meeting with a colleague, salsa dancing, or sharing lunch with a friend.
What effect is all of this online time having on your health? And what—if anything—should you tell your patients about their own Internet use?
As more of our interactions are shifting to online—not only use of social media and computer games, but also shopping, medical appointments, banking, and nearly every other sphere of human activity—many people need help understanding the effects on their health.
"Clinicians are in a position to educate," says Brian A. Primack, MD, PhD, director of the Center for Research on Media, Technology, and Health at the University of Pittsburgh, Pennsylvania.
Adults spent 5.9 hours per day on digital media in 2017, up from 5.6 hours in 2016.
The American Academy of Pediatrics has formulated guidelines for children, but only recently have researchers started to articulate recommendations for adults. Evidence is emerging that the trend to interact through digital media poses both opportunities and threats, they say.
Those who wield their digital tools to enhance their face-to-face social lives are thriving. But when the Internet becomes a substitute for face-to-face interaction, it might starve patients of emotional nourishment.
The observation that people like spending time together dates back at least to Aristotle, and anthropological findings suggest that we were social far back into prehistory. More recently researchers have documented the ways that social networks protect against disease.
People who see more friends more often in real life don't just feel more cheerful; they actually live longer and experience less disability.
The benefits derive partly from practical support, such as transportation to a medical appointment. Friends and family also encourage each other in healthy behaviors.
More subtly, these relationships appear to reduce the risk for disease as measured by immune, vascular and metabolic functions—even gene expression.
But more Americans are now living and working alone than in decades past, and these trends have already raised concerns about mounting social isolation.
In this context, does the opportunity to connect online help or hurt?
- The answer from the studies so far is…both.
One branch of research suggests that the Internet—particularly social media—can attenuate social isolation, particularly for people who face physical barriers to meeting up with other people, such as disability or living in a remote location, or for people with stigmatizing conditions.
"Particularly for older adults, the Internet can really help them stay in contact with their social ties, and help them feel like they're an important part of their social network; that has positive impact on their lives," says Shelia R. Cotten, PhD, a professor in the Department of Media and Information at Michigan State University.
"Research suggests that social media can attenuate social isolation, particularly for people who face physical barriers to meeting up with other people.”
Cotten and two colleagues asked 205 people living in independent and assisted care centers to fill out questionnaires about their feelings of loneliness and social isolation, and about how often they went on the Internet. Many of these people never used the Internet, or had only recently learned how.
The researchers measured loneliness on a 3- to 9-point scale, with 9 the loneliest.
They measured Internet use on a scale where 0 is never, 1 is once every few months, 2 is about once a month, 3 is several times a month, 4 is about once a week, and 5 is several times a week.
The mean frequency of going online was 1.3, and the median loneliness score was 4.0. After controlling for such factors as the number of friends and family, physical/emotional social limitations, and age, Cotton and colleagues found that a 1-point increase in the frequency of going online was associated with a 0.147-point decrease in loneliness.
A variety of similar studies in which Internet use is measured among older people have shown either no effect or a modest benefit. It's harder to measure the effects of Internet use on younger people because most already use the Internet, so a control population can't be assembled.
But some studies looked at specific social media when they first started. For example, a 2007 survey of 800 Michigan State University students found that students who used Facebook had higher social capital (ie, stronger social networks) and better self-esteem.
- It's Not All Positive
Such cross-sectional surveys as these can't show cause and effect; they can only show correlations. It's not clear whether using Facebook makes students more confident and socially connected, or whether more confident, socially connected students are more likely to use Facebook.
And other surveys have shown the opposite. Primack and his colleagues conducted a survey of 1787 adults aged 19-32 years. They found that those who spent the most time using social media were the most likely to feel depressed.
And those in the highest quartile of social media use were twice as likely to report a high degree of perceived social isolation (which Primack equates with loneliness) as those in the lowest quartile.
Primack acknowledges that this study doesn't prove cause-and-effect either. But he thinks it's more likely the social media use is causing the loneliness than the other way around. If people were turning to social media use to cure their loneliness, then they would have become less lonely, he says. "If they are really getting value from the self-medication, we would not find the results that we found," he stated.
Further research is helping tease out the apparent contradiction in the studies done so far, Primack says. He points to a study led by Ariel Shensa, MA, one of his University of Pittsburgh colleagues. In a survey of 1124 students aged 18-30 years, Shensa and colleagues found that students were less depressed when a higher proportion of their social media friends were also face-to-face friends and vice versa.
In fact, there was a dose-response: Each 10% increase in the proportion of social media friends with whom participants had no face-to-face relationship was associated with a 9% increase in odds of depressive symptoms.
And the effect worked in both directions: Each 10% increase in the proportion of social media friends with whom participants had a close face-to-face relationship was associated with a 7% decrease in depressive symptoms.
- "Replacing face-to-face socializing with social media may be the emotional equivalent of replacing fruits and vegetables with sugar and flour in the human diet."
Depression isn't the only outcome that may depend on the way people use social media. Another group of researchers compared data provided by Facebook with California Department of Public Health records.
They found that online behaviors indicating face-to-face social activity, such as posting photos and being tagged in photos, were associated with reduced mortality, but online-only behaviors, such as sending messages, were not.
There's a reason why face-to-face relationships matter, Primack says. "Our bodies have adapted over years to social cues: touch, play, smiles, sounds," he says. "With social media, we try to mimic these things. But to what extent is an emoji smile going to replace a real smile?" Evidence for the importance of physical contact comes from the finding that premature babies fail to thrive when they are isolated in incubators and not frequently held.
An isolated person may become much happier by gaining from access to Facebook just as a person deprived of food will become stronger by eating a loaf of white bread. But someone who meets people less often face-to-face in order to spend more time on Facebook is more likely to become lonely or depressed, just as someone who gives up apples to eat white bread is more likely to become obese or diabetic.
As well, Primack points out, social media can inspire envy. Online, people tend to create versions of themselves as they would like to be, rather than as they are. But they feel inadequate when they compare themselves with everyone else's idealized online profile.
"I would encourage physicians to talk to patients about how they use the Internet," says Cotten. "What are the main reasons? Talk about the positive ways patients can use it—for example, to stay in touch with their social ties." Busy people may be able to keep track of more people and arrange more face-to-face meetings using digital tools, she points out.
On the other hand, some people may find that social media are taking over their lives. "If you are spending excessive amounts of time online, and the amount of time you are spending online is interfering with your other activities of daily living, that's a problem," Cotten says. For example, people who get so caught up online activities that they are missing work or forgetting to pick up their kids from school should take a hard look at their online use.
Such problem users can try timers and apps that keep them from checking social media or engaging in other online activities too frequently. They can also use settings or apps to completely block these activities.
Patients who can't take these steps themselves may benefit from talking to therapists who specialize in changing behavior.
