Social Media and Web-Based Interventions as a Therapeutic Tool for Young Adults With Psychotic Disorders

Instagram, Facebook, Twitter, and Snapchat represent a fraction of tools used by young adults to connect with the world. It is estimated that more than 90% of adolescents own or have access to a social media account (1). These forums are commonly used to solicit friendships, relationship advice, and even diagnose or inquire about diseases. Interestingly, people with psychotic symptoms have been demonstrated to use online social networking for establishing new relationships, maintaining relationships, and seeking online peer support (2). Thus, the Internet may be an avenue for therapeutic intervention for young adults with psychotic symptoms. In a cross-sectional descriptive survey of young adults with first-episode psychosis, participants were asked about their preferences regarding the use of technology for various types of mental health services. The top five technology-enabled services preferred by participants were medication information (96%), information on education, career, and employment (93%), decision-making tools pertaining to treatment and recovery (93%), reminders for appointments via text messaging (93%), and information about mental health, psychosis, and recovery in general (91%) (3).

Nonverbal communication is a critical feature of successful social interaction and interpersonal rapport (4). Patients with psychotic disorders may have difficulty forming and/or sustaining face-to-face relationships. They may pursue less intimate means of communication. A systematic review revealed that psychotic patients use the Internet more frequently than control groups for social networking and use social networking primarily for establishing new contacts, re-connecting with people they had lost contact with, and finding/providing peer support (2). The interest and perceived need of treating psychosis with new technologies could prove to be an effective means to successfully treat patients with psychotic disorders.

The present case report is of a young man with first-episode psychosis whose social media profile revealed evidence of his mental deterioration.

Case

“Mr. B” is a 23-year-old young man with a history of depression and anxiety. He was admitted voluntarily to the inpatient psychiatric unit after a failed attempt of suicide by hanging.

A chart review revealed that by age 18, the patient had progressive interpersonal difficulties resulting in profound social anxiety. He isolated from everyone, including family, and became depressed. One year prior to admission, he began using THC [tetrahydrocannabinol] and cocaine. He changed his name and exercised and dieted excessively, and he posted bizarre pictures and videos on social media.

While on the unit, the patient proudly provided his Instagram and YouTube handles so that he could show the treatment team his videos and pictures. The videos showed him dancing eccentrically to various types of music and talking about random and seemingly unconnected topics. He posted dozens of these videos within 1–2 months. The pictures of him suggested a depersonalized and disconnected gaze as he looked into the camera.

Initially, he resisted medication and grew more paranoid on the unit. Almost daily, he wrote multiple notes describing what he thought his treatment plan should be, and he requested printouts designed to educate him about recommended medications and his diagnosis of schizophrenia. After extensive psychoeducation, Mr. B agreed to start medication. By the time of his discharge, he displayed fair insight about his schizophrenia and showed good judgement by complying with treatment.

Discussion

The above case is exemplary of a typical course in the development of schizophrenia. A slow, gradual prodromal phase preceded the patient’s eventual psychotic state. His first episode of psychosis appears unique in that his online social media presence increased concurrently with his self-isolation. Similarly, a survey of adolescents and young adults ages 12–21 years old with psychotic disorders revealed that 67.5% of subjects noticed changes in their social media habits during symptom emergence, and 15% reported spending more time on social media (5).

During our care of the patient, he requested printed information daily about medications and schizophrenia. The patient, if given access to the Internet, would most likely have searched for the information by himself given his propensity to use social media. This raises the question: Can social media be used as a psychosocial instrument to improve the recovery process? A survey administered to 67 participants between the ages of 18 and 35 recruited from early intervention psychosis programs expressed interest in using social media for receiving mental health-related services. YouTube was the most popular platform, with 85% of participants agreeing or strongly agreeing with the idea of using YouTube to obtain mental health information and support (3).

We know that for many patients psychosis and social withdrawal often present together. Social media platforms and web-based treatment interventions may help address social withdrawal by allowing patients with psychosis an indirect, less physically intrusive return to community, family, and peer interaction. Online technologies can deliver cost-effective, accessible, and time-unlimited support for patients who experience psychosis. A recent systematic review examined web-based interventions that included web-based psycho-education, moderated forums for patients and supporters, integrated web-based therapy, social networking, web-based cognitive-behavioral therapy, and virtual clinical monitoring for the treatment of schizophrenia-spectrum disorders (6). A majority of patients perceived web-based interventions as positive and useful, continuing to employ them during follow-up. There is a promising future for the use of online interventions in the treatment of psychotic disorders, as patients can build important therapeutic and peer support online.

It is important to identify risks and barriers associated with social media platforms and online interventions. Risks include lack of confidentiality, online bullying, and misinformation. Searching for information using search terms such as “I hear voices” and “Am I going crazy?” on popular modalities such as Google, Facebook, and Twitter could introduce patients to unmonitored chat forums that either stigmatize or normalize psychotic experiences (7). Barriers include lack of knowledge on how to search and utilize information on the Internet, as well as lack of interest, time, or resources (3).

In conclusion, there is little research on the efficacy of web-based interventions in the treatment of young people with first-episode psychosis or other psychotic disorders. The implementation of such interventions has exciting potential with the development of accessible, controlled, and safe online environments.

Key Points/Clinical Pearls