Current Pediatric Research

Abstract

Undergraduate students in various scientific disciplines use social media for several reasons. However, excessive use of these applications may lead to a negative impact on mental health. This review aimed to determine the association between social media use and the incidence of depression among undergraduate students. An integrative review was conducted to examine literature published from January 2010-April 2021, on the association between social media use and the development of depression among undergraduate students. Relevant studies were obtained from several electronic databases, and 19 studies met the inclusion criteria. A wide range of selected studies focused on the time spent on social media. Other themes emerging in prior studies include the role of social media addiction, the purpose of social media use, the number of personal accounts, and mediating factors and their role in the development of depression. The findings of this study reveal a correlation between the utilization of social media and the development of depression. Hence, increasing awareness about these relationships may lead to better utilization of social media platforms and mental health promotion among young adults.

Keywords

Undergraduate students, Social media, Depression, Mental health.

Introduction

Depression is the most prevalent mental illness, globally [1]. A majority of people who are diagnosed with depression are exposed to psychological or physical symptoms, which result in increased financial burden due to the costs of treatment [2]. It is estimated that only 50% of individuals diagnosed with major depressive disorder receive medication and appropriate psychological care; moreover, less than 10% receive psychiatric therapy, worldwide [3,4]. Furthermore, the social, genetic, and biological factors underlying the development of depression predispose individuals to the illness.

Social media platforms are a group of applications that depend on the Internet to enable communication between users through pictures or video calls [5]. Social media connects individuals and enhances emotional support, while improving social relationships by providing multiple methods to communicate with individuals with similar interests [6,7]. In recent years, popular social media applications such as Twitter and Facebook have become an essential part of people’s lives, despite their effect on social relationships and mental wellbeing [8].

With recent technological advances in the education sector, there has been an increase in undergraduate students’ social media use to support their academic success [9]. However, due to increased academic pressure and misuse of social media applications, undergraduate students are at risk of burnout, sleep disturbances, and social isolation, which makes them susceptible to depression [10].

The impact of social media use on the development of depression has been investigated in prior studies, albeit with controversial findings [11,12]. Some studies confirm a positive association between social media use and depression, reporting that social media may have a beneficial impact on mental well-being (e.g., higher self-esteem) [13]. However, social media can adversely affect mental health through increased stress and anxiety, social isolation, low self-esteem, and depression [14].

The rationale for conducting this review is to provide an update on the last review conducted on social media use and depression, which was published five years ago. Furthermore, this review examines studies on social media use and the incidence of depression among a specific sample (undergraduate students), and to the best of the authors’ knowledge, there are no published reviews focusing on depression and social media use among an undergraduate student sample group.

Methods and Materials

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in this review. The PRISMA guideline is commonly used to conduct and improve the reporting quality of systematic reviews [15].

Review question

The review question was formulated based on the acronym PICO (i.e., patient, intervention, comparator, and outcome). The PICOT question format was utilized to determine the review question, “What is the association between social media use and the incidence of depression among undergraduate students?” as well as conduct the search process in the databases (Table 1).

Table 1. PICOT Question

Search Strategy

Selection of relevant databases and search items: A search strategy was utilized to find relevant published and unpublished evidence to answer the review question. The electronic search was completed on April 15, 2021, resulting in 244 records. The researcher applied search limits, which included the year of publication (beginning from 2010), the date of search completion, English language, and full-text availability. The Boolean operators "OR" and "AND" were used with key search terms to expand and narrow the search, respectively.

The keywords used for the search included social media-related terms, such as social network sites and social media platforms, depression-related terms such as depression, depressive symptoms, and major depressive disorder, and undergraduate students-related terms such as undergraduate students and young adults (Table 2).

Table 2. Key search terms/words and relevance

The total search results in Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed, Academic Search Ultimate, Education Research Complete, and Arab World Research were 241 studies; two additional articles were added to the review from a Google Scholar search.

Criteria for selecting studies: The research team independently assessed possible evidence that met the inclusion criteria. All duplicate studies were excluded from the analyses. The title and abstract were carefully checked to select relevant studies. In addition, some full-text articles were read, and those that met the criteria were included. Few studies on the association between using social media and depression were excluded, and the reasons for elimination were explained (Figure 1).

Figure 1. PRISMA diagram for included studies

The inclusion criteria were the following: (a) studies published between 2010 and 2021; (b) full text papers; (c) published in English; (d) primary original studies that investigated the association between social media use and the incidence of depression; (e) studies that included samples of young adult students aged between 18-30 years; and (f) studies that included samples of undergraduate students. The exclusion criteria included: (a) studies investigating the association between social media use and depression among adolescents or children aged below 18 years or older adults above 65 years.

Quality assessment of selected studies: The quality of included studies was independently evaluated by the researchers using the tool designed by Hawker et al. [16]. The tool was established to assess the risk of bias as well as to evaluate the quality and usefulness of certain elements in research studies such as the abstract and title, introduction and aim, methods and sampling, data analysis, ethics and bias, findings or results, transferability, implications, and usefulness.

A Likert scale of 4 points, ranging from 1 “very poor” to 4 “good quality,” was used to assess each item. The overall study quality score was the sum of the scores of the nine items, and the final scores ranged from 9-36. Scores ranging from 9-18 are described as poor-quality studies, 18-27 as fair quality studies, and 28-36 as good quality studies.

In relation to the quality of selected studies, the majority of their scores ranged from 17-35, indicating that the selected studies were acceptable and reliable references according to Hawker et al. (Table 3).

Table 3. Quality assessment of selected studies

Extracting the data: This step involved extracting pertinent information from the included studies to find answers to the review question [17]. The primary researcher used a data extraction matrix (Table 4) to extract and summarize the following information on each study: participants, methods, and main findings, which helped enhance the reliability and validity and decrease the risk of bias [18]. Thus, data extraction should involve study variables to answer the review question [18]. Data were extracted from 19 quantitative studies in Figure 1.

Table 4. Study matrix for selected studies

Results

Description of the selected studies

A total of 241 studies were identified by the search process; these studies were published between 2010 and 2020. Initially, 78 articles were excluded, as they were duplicate articles. Of these, 163 were screened by abstract and title to ensure that they met the inclusion criteria. The title and abstract screening resulted in 22 articles, similar to the study’s aim. In addition, the researcher added two studies from a Google Scholar search, resulting in a total of 19 studies for the review [19-37].

This review presents a description of the characteristics of the included studies, followed by a presentation of the extracted themes. The 19 studies focused on the direct and indirect association between social media use and depression. Furthermore, to determine the research themes, a review matrix was developed to arrange the extracted studies by theme. This step helped locate common themes emerging from the selected studies, while identifying the main argument of the study (Table 4).

The majority of selected studies were conducted in North America (n=9), followed by Asia (n=5), Europe (n=3), and the Middle East (n=2). The study design of the included studies can be divided into cross-sectional studies (n=6), descriptive correlational study (n=5), descriptive surveys (n=1), cross-sectional comparative studies (n=1), exploratory studies (n=2), cross-sectional observational studies (n=1), longitudinal correlational approaches (n=2), and cross-sectional correlational studies (n=1). In terms of sample size, eight articles had a relatively large sample (300 students or more), whereas 11 articles had samples of less than 300 students.

A wide range of selected studies focused on the role of time spent on social media. Other studies focused on the role of social media addiction and the purpose of social media use. Furthermore, some studies focused on mediating factors, such as gender, poor sleep quality, anxiety or fear of separation from social media, and poor social contact associated with social media use, and their role in developing depression.

In terms of the inclusion criteria, most studies selected college students, aged 18-30, as participants. Moreover, four studies included students studying in the medical field, whereas 13 studies included students from other scientific fields. Finally, only two studies involved young adults aged between 19-32 years, selected as a nationally representative sample.

The outcome tools used in the selected studies were survey questionnaires (n=19), including a depression-adapted tool (n=16), and a tool developed by the researchers (n=1). Moreover, while some studies developed a tool to measure social media (n=10), others adopted a tool for this purpose (n=5). However, two studies modified a tool from the original researcher.

Regarding outcome tools used to measure depression, five studies [19-23] used the Depression Anxiety Stress Scale (DASS), four used [24-27] the Patient-Reported Outcomes Measurement Information System (PROMIS), and four studies [28-31] used the Beck Depression Inventory (BDI) version-2 comprising 21 items. Moreover, the self-administered patient health questionnaire scale, comprising nine items, was used in three studies [32-34].

Finally, regarding tools used to assess social media use, a majority of the selected studies used self-developed tools in their studies. The types of questions included in self-developed tools varied from questions about time spent on social media, frequency and purpose of use, ability to stay one day without social media use, number of personal accounts, impact of social media on self-esteem and life satisfaction, and Facebook profile activity in the last 30 days [24,27-30,32,34]. Moreover, two studies measured participants’ engagement on the Facebook application only [19,33]. Some scales, including the Bergen Social Media Addiction Scale [23], the Media and Technology Usage and Attitudes Scale (MTUAS) [22], the Active Social Media Use Scale (ASMU), and the Passive Social Media Use Scale (PSMU) [35] were used to assess social media use.

Analysis of results

A total of six themes including time spent using social media, number of personal accounts, purpose of use, social media addiction, mediating factors, and the relationship between social media use and depression emerged from the analysis. These themes are examined in more detail in the subsequent sections

Time spent using social media: Time spent using social media refers to the number of hours that users spend on social media, which is classified into three categories: number of hours, frequency of use, and social media overuse. Regarding social media overuse, Alsabaani et al. [32] revealed that there was no significant relationship between social media overuse and the development of depressive symptoms. Furthermore, Barman et al. [30] found a strong association between the overuse of social network sites and depression and anxiety.

Jeri-Yabar et al. [31] also investigated time spent on social media and found that students who used social media for more than 5 hours, especially Twitter users, had higher levels of depression, compared with students who used social media applications for a lesser number of hours. Similarly, Moreno et al. [34] found that 30% of college students who used Facebook for an average of five hours per day for one year reported sleep and appetite disturbance, low energy, and depressed mood. In line with the previous two studies, Primack et al. [27] and Ahmad et al. [28] revealed that students who used social media for more than six hours had depressive symptoms, compared with students who used social media for 2-3 hours. In contrast, Shensa et al. [25] reported that the time spent on social media was not significantly associated with the development of depressive symptoms.

The frequency of social media use was mentioned in two studies [25,30], which evaluated the association between social media use and the development of depression. The findings of the aforementioned studies emphasized the effect of the frequency of social media use over a long duration on the development of signs of depression; moreover, they found a significant correlation between the frequency of social media use and depression. In contrast, Alsabaani et al. [32] reported no association between the frequency of social media use and the development of depressive symptoms.

Number of personal accounts: The number of personal accounts refers to the total number of social media websites in which personal subscription is registered, and through which the user actively sends text messages, pictures, and videos to other users.

In this review, the role of the number of personal accounts was discussed in two studies. According to Brailovskaia and Margraf [20], having more than one personal social media account can help shy and anxious students enhance their social skills, thus reducing their likelihood of developing depression. Similarly, Barman et al. [30] mentioned that the number of personal accounts on social media had no influence on the development of depression.

Purpose for using social media: Purpose of use refers to the reasons for using social media and its negative or positive impact on mental health. Three selected studies investigated the role of the purpose of social media use on depression.

According to a study by Primack et al. [24], positive experiences on social media such as chatting with family and friends reduced depressive symptoms, whereas negative experiences on social media, such as playing violent video games were strongly related to depressive symptoms. Moreover, Ahmad et al. [28] found high levels of depression among students who preferred to use social media to search for medicine and health-related information. However, medical students who used social media to interact with family and friends did not report depressive symptoms. In addition, Aalbers et al. [35] stated that participants who used social media to chat with strangers or play violent games experienced a sense of self-inferiority, loneliness, and hopelessness, which put them at a higher risk of developing depression.

Social media addiction: With regard to addiction, four selected studies investigated the role of social media addiction on depression. Social media addiction refers to a condition of being dependent on social media applications, either addiction to all types of social media applications, or addiction to specific types of social media applications. According to the Diagnostic and Statistical Manual of Mental Disorders, daily social media use of over six hours is considered a sign of addiction [38].

Regarding social media addiction, Wong et al. [23] found that students who were addicted to social media had higher levels of depression, anxiety, and stress, compared with those who had mild to moderate social media use. However, Tang and Koh [36] reported that around 21% of students who were addicted to social media experienced depression.

Facebook addiction was mentioned in two studies. Al Mamun and Griffiths [33] reported high levels of Facebook addiction among students; moreover, the results revealed a positive correlation between Facebook addiction and depression. Similarly, Brailovskaia and Margraf [19] found a strong correlation between Facebook addiction and personality traits such as narcissism and other mental health issues, such as depression, anxiety, and stress symptoms.

Mediating variable/or factors: Regarding mediating variables or factors, eight selected studies discussed the role of mediating factors in the development of depression. Mediating factors include gender, poor sleep quality, fear of loss or separation from social media, poor self-esteem, decreased life satisfaction, and poor social contact associated with social media. Mediating factors, or confounding, moderating factors, refer to an explanation of the relationship between the independent and dependent variables by outlining how and why the relationship exists.

Similarly, Saglam et al. [29] revealed that poor sleep quality, mediates the association between social media use during sleep time and depression and anxiety. In addition, a study by Zeeni et al. [22] found that continuous fear of separation from social media use was associated with an increased probability of the development of depression.

In line with previous studies, Elhai et al. [21] found that participants in the social media loss group demonstrated more fear of loss and showed signs of anxiety owing to the imagined loss of their smartphone. Thus, their emotion and fear mediated the relationship between imagined loss of smartphone and depression, anxiety, and stress. Moreover, Brailovskaia and Margraf [20] reported a positive association between poor self-esteem, decreased life satisfaction, and general use of social media, and consequent development of mental illnesses such as depression.

Furthermore, Shensa et al. [26] reported that poor social contact associated with social media use and the absence of direct personal interaction with social media contacts were related to the development of depression. Similarly, Lee et al. [37] reported that using social media during face-to-face interaction causes poor social contact, increases social isolation, thus negatively affecting social relationships and increasing the risk of depression and anxiety.

Finally, the role of gender was mentioned in two selected studies in the current review. Alsabaani et al. [32] reported that the prevalence of depression was higher among female than among male students. Moreover, they emphasized the role of Saudi culture’s restrictions on women as well as the historical trajectory of economic, social, psychological, and family problems in the development of depression among female students. Similarly, Ahmad et al. [28] reported higher levels of depression among male medical students who used social media applications, compared with their female counterparts.

Social media use and depression relationship: The association between social media use and depression was the result of the statistical analysis conducted by researchers to assess the relationship between social media and depression using a correlational method. Some studies reported a significant positive correlation between social media use and depression, while others reported a negative correlation between social media and depression.

A positive correlation between social media use and depression was found in five studies. Aalbers et al. [35] found that social media use was positively correlated with depression, wherein an increase in social media use scores resulted in an increase in the total depression score. Similarly, several studies have reported a positive correlation between social media use and depression [27,28,30,31].

However, only the study by Alsabaani et al. [32] study revealed a negative correlation among medical students in Saudi Arabia who used social media.

Discussion

This integrative review was designed to investigate relevant evidence on the potential association between social media use and depression among undergraduate students. In the selected studies, the most commonly measured outcome was depression, in addition to other mental illnesses such as anxiety. Emerging themes on the risk factors for the development of depression included time spent on social media; purpose of social media use; number of personal accounts; social media addiction; and mediating factors in the development of depression such as gender, poor sleep quality, anxiety, fear of loss or separation from social media, poor self-esteem, decreased life satisfaction, and poor social contact associated with social media use.

Moreover, the results of the included studies showed inconsistent and varying findings regarding the association between the two variables. However, most researchers have reported a complicated and controversial association between social media use and depression. However, some studies investigated the possible role of mediating factors in the development of depressed mood.

This review showed a positive association between social media use and depression according to the finding of Primack et al. [27], Ahmad et al. [28], Jeri-Yabar et al. [31], Aalbers et al. [35], and Barman et al. [30]. However, this result is inconsistent with the findings of Alsabaani et al. [32] and Brailovskaia and Margraf [19], who found that using social media for long hours and having more than one personal account on social media applications helped reduce depression by decreasing social isolation and enhancing communication skills.

This review revealed that spending more time and the overuse of social media applications was associated with the development of depression. This finding is supported by Barman et al. [30], Jeri-Yabar et al. [31], Moreno et al. [34], and Primack et al. [27]. However, these results are inconsistent with the findings of Alsabaani et al. [32] and Shensa et al. [25] who found no relationship between the number of hours spent on social media and the development of depressive symptoms.

The main finding of the current review was that students who preferred to use social media for the purpose of identifying health and medicine-related information had higher levels of depression, compared with students who used social applications to interact and communicate with their relatives and friends. In addition, this review revealed that users, who used social media passively to chat with strangers or play violent games, experienced a sense of self-inferiority, loneliness, and hopelessness, which made them more susceptible to developing depression. This result is similar to the findings of a study conducted in Pakistan by Ahmad et al. [28] and two other studies conducted in the United States by Aalbers et al. [35] and Primack et al. [24] who found that the purpose of using social media plays an important role in the development of depression.

In addition, this review highlights the impact of addiction on social media. Some authors reported that students who were addicted to social media had higher levels of depression, compared with those who were not addicted to social media. However, others have reported that addiction to a particular type of social media such as Facebook plays a crucial role in the development of depression. This result is in line with the findings of a study conducted in Hong Kong by Wong et al. [23], a study conducted in Bangladesh by Al Mamun and Griffiths [33], a study conducted in Germany by Brailovskaia and Margraf [19], and another study by Tang and Koh [36] in Singapore.

Furthermore, some evidence in this systematic review highlights the role of mediating factors in the development of depression. Among these factors, poor sleep quality associated with social media use has been reported as a mediating factor in the development of depression [29]. Moreover, fear of separation from using social media, poor self-esteem, decreased life satisfaction associated with frequent social media use, poor social contact, and loss of face-to-face contact associated with social media use have been reported as mediating factors in the development of depression [20,22,26,37, 38].

The influence of gender, associated with social media use, in the development of depression was also revealed in this review. As reported by Ahmad et al. [28] male undergraduate medical students who used social media had higher levels of depression, compared with female medical students. This result was in contrast to the findings of Alsabaani et al. [32] that reported higher levels of depression among female medical students who used social media, compared with their male counterparts. This finding was a result of Saudi’s cultural restrictions on women and other risk factors that cause women to spend more time on social media applications to escape from social isolation.

Limitations

Several limitations emerged from the selected studies in this review. First, some included studies employed a convenience sampling method; moreover, some studies had small sample sizes, which reduced the generalizability of their results. Second, few studies focused on Facebook use over other social applications, which caused a bias and influenced the generalizability of the results.

Third, some selected studies not only assessed the effect of social media use on the development of depression, but also measured other mental illnesses such as anxiety and personality disorders. This made it difficult to determine whether social media use alone is a source of depression and other mental illnesses, or depression and other mental illnesses lead to increased frequency and passive use of social media, which result in addiction to social media.

Finally, some selected studies used self-reports and self-developed questionnaires to measure social media use, which may not provide reliable information about students’ activities on social media applications. In addition, other studies have not clearly mentioned the tools used to measure social media use, while others failed to report the validity and reliability of the tools used in their studies.

Conclusion

The findings of the current review are likely to be beneficial to academic faculty and advisors alike as they are in direct contact with undergraduate students and the researchers share significant contributions clarifying the role of social media in the development of depression among undergraduate students. Hence, universities and colleges both have a responsibility towards their students to establish educational programs and/or awareness campaigns on the campus to educating undergraduate students about the potential hazards of social media use on mental health. Such educational programs/campaigns can include group discussions, consultations with academic advisors or on campus counselors to enable students to express their thoughts and feelings, which in turn can help cultivate supportive academic environment.

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