Following Our Digital Footsteps

by Ean Tam, May 19, 2021

On January 21st, 2020, the United States reported its first case of COVID-19 in Washington state. Over the course of a year, offices emptied, schools closed, and normal life disappeared. By April 2021, over 553,000 Americans had passed away due to the pandemic. Now, as vaccine shots continue to make their way into people’s arms, the hope of defeating the pandemic appears more attainable. The vaccine is our shot back to the workplace, the classroom, and, some would say, back to normal life.

While suppressing this respiratory disease itself may be possible, many people struggle to take a deep breath and relax. For more than a year, across the country Americans have been sheltering in their homes, taking in the world through screens and behind masks. They have been waiting to return to work, hoping to regain jobs they lost at no fault of their own. It will take time for people to regain a sense of control over their lives and examine the mental health effects of the pandemic.

Perhaps we can comprehend how the pandemic played into the worst sides of ourselves. How did transitioning to a life online affect us? What will be our ‘new normal’ post-pandemic? How do we want to discuss mental health? To answer these questions, we should examine the research into our social and online behavior, including new techniques in studying social media activity.

A Life Online

When isolation orders began, we observed the panic: not as frenzy crowds going berserk in the streets, but in the simplest of manners: lining up at the supermarket. Under the threat of prolonged lockdown, citizens translated their insecurities through their wallet. In the United States, where consumerism is a part of our culture, our spending behavior can exemplify our human instincts: “Cash, and the fantastic appeal of what money can buy… provide a way for humans to distance themselves from the disturbing realization that they are animals destined to die” (Arndt et al., 2004). Certainly, not everyone assumed COVID-19 was going to be the ultimate scourge of the human race, but the mindset was there. As a reflection of that mindset—that we as humans can have some control over our lives—we decided to wipe out the supermarket shelves before COVID could wipe us out.

Of course, the online world to which we were regulated put us face-to-face with another nuisance we had already been trying to grapple with: misinformation. Unfortunately for us, online misinformation has only become worse. In beginning of the pandemic, so little was known about SARS-CoV-2, the virus that causes COVID-19. Once a rumor, half-truth, or plain lie made its way online, there was no way of knowing how far it could travel. But it is clear that unreliable sources induce panic and anxiety, stoking our fears of the current situation, encouraging us to prepare more (Usher et al., 2020; Johal, 2009).

When ventures outside of our homes are limited to stocking up on groceries, the possibilities for personal connections are lost. Small talk is hard to come by, especially when you are six feet apart, wearing a mask, and staring through the glare of plexiglass. Physical interaction has become impersonal. Even the relationships established before the pandemic have been hurt. The online connection has been unable to keep up with the loneliness. While we can turn on our cameras to see each other’s faces on screen, the interaction is not a proper substitute for in-person contact (Lippke et al., 2021). In a study of 212 Swiss undergraduate students, researchers found that the students, because of the pandemic, were increasingly working alone and not engaging in networking with their peers. Students’ depressive and anxiety symptoms also increased. The concerns about the students’ minds ranged from the “fears of missing out on social life to worries about health, family, friends, and their future” (Elmer et al., 2020). For mourners who require “restorative activities (e.g., travel, spending social time with friends),” those options vanished (Lee and Neimeyer, 2020). The emotional connections that would have helped no longer do, and the strength of the friendship has diminished. This faltering sense of belonging and attachments to others can manifest itself in our physical and mental health (Baumeister and Leary, 1995).

It is no secret that internet use and mental health are intertwined. More time spent on the internet affects our social interactions and increases the chances of cyberbullying. It appears the relationship between internet use and social interactions can go either way: problematic internet use (PIU) can be both the cause and the result of diminished social interactions. When internet use is the cause, social interactions suffer because of depression, neglect of offline obligations, and obsessive behaviors, all of which are linked to PIU. When PIU is the result of diminished social interactions, the internet is seen as a coping mechanism—a world to which people can escape (El Asam et al., 2019).

However, the world people enter is not always so agreeable. Excessive internet use has a profound impact on adolescents because they are not only victims of cyberbully, but also encouraged to take part in it. Online communities offer opportunities for validation. At times, participating in cyberbullying is a way for some adolescents to ‘fit in’ with their online counterparts. Moreover, an adolescent who engages in such internet behavior can be expected to develop PIU (Chao et al., 2020). It appears that most of the time, victims of cyberbully do not allow the abuse to end with them. They will have “a desire to respond, which may encourage others to join the fray leading to a potentially long and drawn-out series of increasingly abusive and antagonistic communications” (Chao et al., 2020).

Before lockdown, excessive users of the internet had the ability to separate themselves from their devices. However, once life went online, that opportunity disappeared. We all, in a way, became problematic internet users. A life online, while necessary for the past year, has shown to be harmful to our mental well-being.

Back to Normal?

When we eventually emerge from this pandemic, the cloud of lockdown will still hang over us. One of the lingering concerns will be the home as the petri dish. Throughout this pandemic, citizens have created their own fortresses, hoping to keep the COVID invader at bay. Every trip outside of the home was a potential for letting an intruder in. That is why we wiped down all our groceries and bathed ourselves in hand sanitizer after every door handle. The pressure to keep the home decontaminated has been especially hard on those living with vulnerable groups like the elderly.

Retreating to our homes for the past year has proven to us that some things are simply no longer worth going out: movies, restaurants, shopping. However, “even people who do not become housebound may become fastidious germaphobes, striving to avoid touching ‘contaminated’ surfaces or hugging people or shaking hands” (Taylor and Asmundson, 2020). Pandemic sanitation standards will persist, similar to how some American families maintained their parsimonious, self-sufficient lifestyles after the Great Depression (Taylor and Asmundson, 2020).

The stress of yourself being a carrier and potential hazard to those around you can be exacerbated when living conditions are tight. When living conditions are limited, tensions can flare. Unfortunately, some people find themselves trapped at home with COVID outside and an abuser inside, making their situation a possible source of post-traumatic stress disorder (PTSD) (Taylor and Asmundson, 2020).

For those who have contracted COVID-19, some have had to deal with guilt for possibly infecting others, embarrassment for having contracted the disease while others did not, and shame for not protecting oneself enough. Not even our healthcare workers have been exempted. In Italy, Daniela Trezzi, a 34-year-old nurse, took her own life in March of 2020 after she had tested positive for COVID-19. Trezzi’s colleagues reported that her suicide may have been the result of her concerns of having infected other people (Giuffrida and Tondo, 2020). As COVID-19 surged in New York City last April, Dr. Lorna Breen, an ER doctor at New York-Presbyterian Allen Hospital, committed suicide. The virus had taken the lives of many of Dr. Breen’s patients. Despite the overachieving and dedicated passion to her job, Dr. Breen’s family believed she “was devastated by the notion that her professional history was permanently marred and mortified to have cried for help” (Knoll et al., 2020).

Plenty of people will be able to return to normal life post-pandemic, to go back on the street as if nothing has changed. But for many members of the Asian-American and Pacific Islander (AAPI) community, this is an impossibility. A wildfire of misinformation spreads (and continues to spread) across the internet, pinning a substantial number of American citizens as walking embodiments of SARS-CoV-2. Therefore, for AAPIs, returning to a normal life post-pandemic does not mean traveling down the street as if nothing has changed. As the United States begins to open, we are already seeing increases in racist attacks against AAPIs. We have seen this before. In 2014, Ebola was blamed on Africans because it was deemed an “African problem” (Usher et al., 2020). The ease of scapegoating specific demographics is an example of maladaptive coping “where coping is emotion-focused rather than problem-focused” (Cho et al., 2021).

We would like to think there is a chance for a return to normal. However, for many people, this is an unlikely future. Quarantine and the pandemic experience have affected the mental health of citizens across the globe. The pandemic has left us lonely, guilty, and fearful. It has forced some people to channel their insecurities into counterproductive behaviors. Behaviors that prevent us from regaining a sense of camaraderie and interconnectedness—some things we all lost this past year in quarantine.

Putting Our Online Activity to Good Use

Although living our lives on the internet has strained everyone, there may be something to gain from our past year online. In recent years, mental health researchers have turned their eyes to social media. With every post, like, or share, there may be a hidden meaning waiting to be deciphered. A variety of social media websites have been utilized for possible insights into specific mental health issues. Twitter is a popular site for study. It has been used for learning about detecting signs of depression and suicide (De Choudhury et al., 2013; Tsugawa et al., 2015; Coppersmith et al., 2016). Instagram, Reddit, and Tumblr have been used to study depression, suicide, and anorexia, respectfully (Reece and Danforth, 2017; Shing et al., 2018; Chancellor et al., 2016).

Taking advantage of machine-learning to comb over patients’ extensive social media activity, researchers have found indicators of mental health illnesses. For example, researchers classified tweets of suicidal individuals by their expressed emotions, emoji usage, and frequency of tweets. They found that tweets usually expressed sadness then anger after a suicide attempt, and that frequency of emotional tweets increases while emoji prevalence decreases (Coppersmith et al., 2016). The machine-learning systems allow for detecting these indicators with accuracy as high as 80 to 90 percent. This technique of combining computing power with psychiatric evaluation has led to the term “digital psychiatry” (Chancellor and De Choudhury, 2020). The focus on social media is particularly helpful in studying younger generations. Regardless of race or medical history, a younger age has been “the only significant predictor of blogging and social networking site participation” (Chou et al., 2009).

Northwell Health, New York state’s largest healthcare provider, has realized the importance of using social media for the purpose of engaging with patients as soon as possible. Since 2013, Northwell’s Early Treatment Program (ETP) has specialized in treating adolescents and young adults suffering from psychotic symptoms. Dr. Michael Birnbaum, Director and founding member of the ETP, studies the application of social media as an indicator for psychosis. I spoke with Dr. Birnbaum to learn more about his research with social media and its implications.

“This line of research was happening in the world of computer science, but not so much in psychiatry,” Dr. Birnbaum explained. “The idea sort of organically arose through reading the exciting literature on machine-learning and social media. Thinking about some of the major challenges and obstacles to delivering effective care, we came up with this solution.”

To perform his studies, Dr. Birnbaum and his colleagues retrieved social media archives donated by participants. These databases were downloaded straight from social media websites and then inputted into machine-learning systems provided by computer scientists from institutions like IBM, Cornell Tech, and Georgia Tech. The magnitude of data for these studies were immense. For instance, in one study, from just 223 research participants, Dr. Birnbaum and his team had collected 3,404,959 Facebook messages and 142,390 images. With this Facebook data alone, they found that the machine-learning system could identify research participants who had schizophrenia spectrum disorders (SSD) and mood disorders (MD). In terms of posts and messages, those with SSD were more likely to use words of sensory perception, those with MD were more likely to make references to the body, and SSD and MD groups were both more likely to use curse words. When it came to Facebook photos—a more abstract source of analysis—Dr. Birnbaum and his research team found that those with SSD and MD were more likely to post smaller photos by dimension, and the hues of photos from MD participants were more blue and less yellow (Birnbaum et al., 2020).

Now, while the volume of information is essential to the experiment, the social media archives are not limited to just the research participants. Within these archives, you can find private messages sent by the research participant and messages sent from second parties whom the participant was communicating with.

“One of the other ethical issues is the fact that there are a ton of secondary subjects: all of the friends and connections to other users who don’t necessarily agree to have their data donated and analyzed, and so that’s something that, as a team, will need to sort of grapple with,” Dr. Birnbaum explained. To handle this ethical issue, Dr. Birnbaum’s studies had to eliminate the data from these secondary parties. So, while these secondary subjects may not have their private messages inputted into a machine-learning system, there is no denying that those messages are being stored somewhere at some point. It will be up to the patient to inform his or her friends that their conversations may eventually find their way into a stored database. Consent, conservation, and confidentiality of social media information are only some of the big hurdles of digital psychiatry (Wongkoblap et al., 2017). However, Dr. Birnbaum believes that with the correct system in place and an understanding from the public, the application of machine-learning can find success in psychiatry.

“This shouldn’t be about surveillance or taking the power away from the patient. It’s just the opposite. In my mind it’s creating a way for the patient to be able to learn more about themselves and also share it with their clinician. Just like when you go to see your doctor who orders a blood test or an X-ray, you donate your blood to inform because it’s going to improve your care. Though most people don’t like taking their blood, similarly, I imagine a situation where the benefits would be clear and patients would be willing and interested in donating their digital data to inform their care in a meaningful way.”

Furthermore, Dr. Birnbaum highlighted a key issue in psychiatry: the reliance on self-reported information. It has been shown that self-reported data can be unreliable and underestimate health issues (Wallihan et al., 1999; Newell et al., 1999). Dr. Birnbaum elaborated, “We just are notoriously bad at this—all of us—at describing our own behaviors. Most of us can’t remember what we ate for dinner a few days ago, and so I think that these things can be immortalized in digital data, and so we can accept it more readily and use it.”

And in terms of the depth and perception from which we can learn, social media information may be the closest thing psychiatrists can have to 24/7 observation of their patients. Retrospective analysis of a patient after they have been admitted into the hospital is not the best solution. Social media information may hold the key.

“A patient sees the doctor periodically, and they meet for a certain amount of time and then that’s it,” Dr. Birnbaum said. “You don’t really know what’s happening in between meetings beyond patient self-report. The [social media information] provides information about what was going on between sessions. So, you can learn a lot more about, or rather from a different source and a more objective source, about what people are doing, thinking, and feeling.”
Of course, social media information is no substitute for in-person meetings. For Dr. Birnbaum, “I imagine a situation where someone donates their digital data a day or two before they come to meet me in my office, and then we can discuss the findings and determine whether or not we need to change the treatment plan.”

Although Dr. Birnbaum explained earlier that routine treatment involves monthly meetings with patients, the timing of when a patient should donate their social media archives is not exactly clear: “That is something that has yet to be empirically explored. Maybe it’s once a month when they come see me, maybe not. I could imagine a situation where it is done at the beginning of care and maybe perhaps periodically after that. I think it depends on what information we’re after, what we’re looking for, and how each individual uses social media.”

In the end, social media activity would just be one component of digital psychiatry. The way Dr. Birnbaum sees it, “Social media is a piece of the puzzle. They’re also people looking at speech, facial movements, wearables, cell phone data. All of this stuff paints a picture. A more comprehensive picture.”

What’s the Point?

On April 9th, The Wall Street Journal published an article titled, “Loneliness, Anxiety and Loss: the Covid Pandemic’s Terrible Toll on Kids.” In it, the author, Andrea Peterson, details the faltering grades, confidence, and motivation of young students. One 13-year-old stated, “[I]t’s been a lot harder to make friends and talk to new people… I feel like a lot of us drifted apart… It has set in that I’m alone” (Peterson, 2021).

With vaccines getting administered around the world, our public health appears to be on the right track. For many of the students who spoke with Peterson, transitioning back to in-person social activities will be difficult, but nonetheless, they will finally be in-person. Hopefully, for all of us, returning to in-person work or school will be the remedy we need. But the final obstacle we will face is the way we confront mental health as a society.

When The Wall Street Journal shared Peterson’s article on its Twitter profile, many of the comments were supportive—a lot of teachers and students voicing their approval with the awareness raised by the article. Then, of course, there were comments like these:

https://twitter.com/HRHSherlock/status/1380646040714375170

https://twitter.com/eagles2sixers/status/1380923582268764164

It would be quick and easy to say kids these days are just soft. It would be quick and easy to say there are more pressing matters than this. But the people who choose these quick and easy solutions seem to forget that we are all wired differently. We process things differently. Just as physical abilities differ from person to person, our ways of handling strains of our mental health differs. And to those who say the deaths from COVID-19 are more important: yes, preventing deaths is the number one priority, but the pandemic will be over. Can we talk about mental health effects then? Or would we have forgotten about it already?

It is unfortunate to think that these attitudes can exist within families, preventing people from getting the help they need. Whether it be depression or psychotic disorders, stigma exists everywhere. The family unit is not always equipped to understand the needs of someone suffering from a mental illness.

“For the most part, it’s impossible to tease apart providing good care to a patient without involving their family,” Dr. Birnbaum told me while explaining the role of family at the ETP. “So, it’s critical that the family understands what’s happening and has a connection to the treatment team, is involved in the treatment decisions in some capacity, and knows how to be most helpful and supportive for their child.”

It is no secret that there is a clash of how we discuss mental illness. Some people, due to culture or age, like to keep it under the rug, while younger generations tend to be more open about mental health. Those who like to keep a tight lip about it find themselves being blamed for being a part of the problem. Well, to put it simply, they are. I would hope people do not see that as a political opinion. It is informed medical advice.

When asked about breaking the stigma surrounding mental health and culture, Dr. Birnbaum explained, “I think that’s part of the work and that’s part of the advocacy. And part of the excitement of early intervention is sort of getting the message out that there are resources and tools and help available. The more we talk about it, the better.” He added, “Hopefully that’s something that we can do by changing society.”

Changing society will be no easy task. It will take time, just like waiting for this pandemic to be finally over. The ‘new normal’ waiting for us will ultimately be defined by us. If we decide to keep things the status quo, then that is what we should expect. As difficult as the past year has been, we ought to make the most of it. With the new advancements in machine-learning, we can learn from the online activity we amassed in quarantine. Work like Dr. Birnbaum’s shows that studying our online presence can improve the way we comprehend mental health. We can learn more about ourselves, mental health, and possibilities for early treatment for young people. When it comes to pandemic, the light at the end of the tunnel seems to be getting brighter. While we cannot say the same for mental health, our digital footprints can help lead the way.


Work Cited

@CortezGeovanny. “Kids are getting softer and softer with each generation.” Twitter, 9 Apr 2021, 9:20 p.m., twitter.com/CortezGeovanny/status/1380692134659940352.

@eagles2sixer. “I’m sorry the kids had to stay home on their phones for a year but please. Did the kids that worked in dangerous factories or lived during the blitzkrieg or black in the south in the early 1900s or during the depression or a million others not have it 1000X worse?” Twitter, 10 Apr 2021, 12:40 p.m., twitter.com/eagles2sixers/status/1380923582268764164.

@HRHSherlock. “Yes, this is all very sad, but over 560,000 Americans are dead.” Twitter, 9 April 2021, 6:17 p.m., twitter.com/HRHSherlock/status/1380646040714375170.

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