Evaluating Displayed Depression Symptoms on Social Media Sites

doi:10.4236/sn.2013.24018

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Social Networking, 2013, 2, 185-192

http://dx.doi.org/10.4236/sn.2013.24018 Published Online October 2013 (http://www.scirp.org/journal/sn)

Evaluating Displayed Depression Symptoms on Social

Media Sites

Megan A. Moreno1, Erin Kelleher2, Megan Pumper1

1Department of Pediatrics, University of Washington, Seattle, USA

2Department of Pediatrics, University of Wisconsin, Madison, USA

Email: [email protected]

Received July 18, 2013; revised August 23, 2013; accepted October 10, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Social networking sites (SNSs) are immensely popular and allow for display of personal information, including refer-

ences to depression. Evaluating displayed content on a SNS for research purposes requires a systematic approach and a

precise data collection instrument. The purpose of this paper is to describe one approach to the development of a re-

search codebook for depr ession so that others may develop and test their own codebooks for use in SNS research. The

depression SNS research codebook was grounded in ethics, theory and clinical criteria. The key elements in the code-

book developmental process included an iterative team approach to develop variables of interest and data collection

sheet layout. Training protocols involve coding practice and reliability assessments. Interrater reliability remains a

critical assessment tool. Codebook successes include consistently high interrater reliability. Challenges include time

investment in coder training, SNS server changes, and social or cultural norms regarding public displays of mental

health. We provide detailed information about a systematic approach to codebook development so that other researchers

may use this structure to develop and test their own codebooks for use in SNS research. Future directions for the code-

book include expanding areas of interest such as anxiety or other depression evaluation criteria, and expansion to other

SNSs such as Twitter.

Keywords: Component; Formatting; Style; Styling; Insert

1. Introduction

Social networking web sites (SNSs) may present new op-

portunities to investigate depression, particularly among

adolescents and young adults. The vast majority of ado-

lescents and young adults use a social networking site

such as Facebook [1-3]. SNSs allow members to build a

personal web profile, to communicate with others and to

build a social network. Profile users may incorporate text,

photos, graphics, audio and video to build a personal re-

presentation of their identity.

Through content displayed on a SNS profile, profile

owners may give researchers and health care providers

insight into aspects of their behavior that are not always

apparent in offline life. These disclosures may include

references to depression symptom in the form of “status

updates,” personally written text describing the profile

owner’s current experiences. Previous work found that

approximately a quarter of publicly available Facebook

profiles of undergr adu ates d isplayed d ep ressio n sympto m

references, and a small proportion of profiles displayed

depression symptoms in patterns consistent with the Di-

agnostic and Statistical Manual (DSM-IV) criteria for a

major depressive episode (MDE) [4,5]. Additionally, dis-

play of depression symptoms was positively associated

with reporting depression symptoms using a clinical

screen [6].

Why might a profile owner display feelings of depres-

sion in such a public online venue? Previous work illus-

trates that computers elicit higher levels of self-disclo-

sure and uninhibited personal expression compared to

offline interactions [7]. Adolescen ts report that they o ften

disclose more about themselves on SNSs than they do in

person [8]. Further, the social risk hypothesis suggests

that humans try to minimize social risks in order to

maintain ties to a group [9]. It has been posited that peo-

ple with depression will change their behaviors to make

“safer” social decisions in order to avoid social failures.

Thus, social networking websites may present a venue to

those with depression th at feels safer for expressing emo-

tion durin g per i ods of isolation.

M. A. MORENO ET AL.

186

These online displays of health risk behaviors are im-

portant as they give health care provider s and r esear cher s

new insight into adolescent health concerns that are

clearly linked to morbidity and mortality among this po-

pulation. The most common form of depression within

the adolescent and young adult age group is major depre-

ssive disorder, which has a yearly incidence of approxi-

mately 8% [10,11]. Additional 22% of adolescents and

young adults suffer from “sub-diagnostic” levels of de-

pressive symptoms [12]. Both those with a major de-

presssion diagnosis and those with depression symp-

toms experience impaired functioning and morbidity [13 ].

Adverse outcomes of depression include increased rates

of substance use, co-morbid psychiatric conditions and

suicide [14-17].

Despite the prevalen ce of depression in th is popu lation,

college students struggling with depression symptoms

are frequently undiagnosed as many students do not per-

ceive a need for help or do not seek clinical services [10,

11,18]. While 30% of college students report feeling so

depressed in the past year that it was difficult to func-

tion, only 10% of co llege students repo t seeking an y type

of mental health care in the past year [19,20]. Concerns

about the stigma related to mental illness are also associ-

ated with less perceived need for help and decreased

treatment seeking behavior [21]. Recent media stories

highlight tragic suicides of young adults that were refer-

enced on Facebook prio r to being carried out; illustratin g

the urgent need to better understand the validity of dis-

played references to depression and other mental health

concerns [22]. Thus, social media could provide an in-

novative and complementary approach towards early

identification of depression.

Barriers to evaluation of social media for displayed

depression disclosures include concerns about subjectiv-

ity in coding or bias in evaluation of social media sites.

Thus, in order to establish SNSs as a credible approach

for understanding depression displays, a framework for

consistency and reliability in evaluation and measure-

ment of SNS profiles is essential. The purpose of this

paper is to describe one approach to the development and

use of a research codebook to evaluate adolescents’ dis-

played references to depression symptoms on Facebook.

Our intention is to provide a framework on which re-

searchers or clinicians may further develop and adapt

their own codebooks for use with mental health SNS

research. Given that SNSs may rise and fall in popularity,

our goal is to provide a framework that is usable and

adaptable to researchers as new technologies and new

mental health topics of interest emerge over time.

Foundation of the Codebook

In developing the codebook, we began with a review of

salient literature to contribute to the foundations of the

codebook’s theoretical, methodological and clinical

foundations. We first investigated theoretical models to

guide its structure so that we could understand the role of

SNSs in adolescents’ lives. The Media Practice Model

describes that adolescents choose and interact with media

based on who they are, or who they want to be, at the

moment [23]. This model influenc ed our early interest in

viewing SNSs as representations of adolescents’ identi-

ties and is supported by literature that suggests that ado-

lescents may disclose more about themselves in online

venues than they do face-to-face [24].

Codebook development was further influenced by a

review of the literature for qualitative methods. As

qualitative data can provide rich data, sometimes called

“thick description,” of experiences or events we wanted

to maximize the reliability in collecting and interpreting

such data [25]. We followed other investigators’ strate-

gies for interpreting qualitative interview data, such as

holding frequent team meetings to discuss and refine the

coding structure as it evolved [25,26].

Finally, in developing codes for references of depres-

sion we consulted established clinical criteria: the Diag-

nostic and Statistical Manual of Mental Disorders (DSM-

IV) [4]. By grounding the coding scheme on clinical cri-

teria, our goals were to maximize the clinical app lication

of data obtained via SNSs and to promote translation of

findings into further clinical research. Further, we wanted

to provide robust and detailed criteria that coders could

apply during each profile evaluation, so that coders did

not need to apply personal or subjective judgment to dis-

played content. Thus, references to depression symptoms

were defined using the DSM-IV symptom criteria for a

MDE [4].

2. Codebook Development

2.1. Confidentiality

In creating the codeboo k, a first objective was to address

ethical concerns that may arise in evaluating data from

SNS profiles. Consistent with recommendations by the

Institutional Review Board, a priority area was to de-

velop protocols towards maintaining confidentiality of

the data obtained from prof iles. This focus on con fidenti-

ality was applied to the data collection stage. Th e coding

protocol specified that data recorded from profiles would

never be identified by name but by an assigned code

number. Confidentiality protoco ls have also been applied

to presentation of data through papers or at conferences.

For example, when presenting direct text quotes from

participants’ profiles, quotes are always slightly altered

so that an online text search will not match the quote to

the participant’s profile. Further, no other identifiable

information is documented with text examples. If names

are displayed with in the text they are taken out and re-

placed with the label of “profile owner” or “friend”.

M. A. MORENO ET AL.

187

2.2. Profile Security

SNS profiles may be “publicly available” such that pro-

file content is accessible by the entire online social net-

work, or “privately available” in which profile content is

only available with explicit permission of the profile

owner. Many early studies focused on SNS profiles that

were publicly available [27,28]. In the past few years,

both privacy settings and the culture of privacy on Face-

book have changed, and many users favor settings that

limit public access. However, findings from one study

illustrated that many participants were open to allowing

their profile content to be accessed by researchers [29].

Thus, researchers may consider asking participants to

Facebook “friend” a research assistant to allow content to

be mutually viewable between the research team and the

participant.

2.3. Defining Variables of Interest

To develop a coding scheme for the complex variable of

depression, we used an iterative process. The first step

was establishing clinical criteria to operationally define

depression symptoms. References to depression symp-

toms were defined using the Diagnostic and Statistical

Manual of Mental Disorders (DSM-IV) symptom criteria

for a Major Depressive Episode (MDE) [4]. The criteria

for MDE included depressed mood, loss of interest/

pleasure in activities, appetite changes, sleep problems,

psychomotor agitation or retardation, energy loss, feeling

worthless or guilty, decreased concentration or suicidal

ideation [4].

Thus, text references were considered a depression

symptom reference if they fit one of the depression crite-

ria by keyword or a synonym. For example, one symp-

tom keyword of major depression is “hopeless,” there-

fore a status update stating “I feel hopeless” would be

coded as a reference to depression. The term “giving up”

is a synonym of “hopeless,” therefore, a status update

disclosing “I feel like giving up” would be coded as a

reference to depression as well. Status updates that

clearly referenced a person other than the profile owner

(i.e. “Molly is sitting next to me in class and she looks

sad”), or references to the common situ ation al expe rience

of having a bad day (i.e. “I’m having a depressing day”)

were not considered depression references.

The next step involved applying these coding criteria

to the SNS of choice; initial codebooks were developed

to be applied to Facebook. Applying these clinical crite-

ria to a pilot sample of profiles resulted in identification

of further keywords and synonyms linked to the variable

of interest. Team discussions of both findings from pro-

file content, as well as notes on the evaluation process

itself followed. If modifications were suggested, the

process began again with the coding of a practice set of

profiles and then presenting findings and notes on the

process to our research group. This process helped fur-

ther develop the coding schemes.

2.4. Preparing the Codebook

Following this iterative process, the codebook protocol

was created. This included documentation prompts for

each proposed depression symptom including: a descrip-

tion of the va riable including any relevant clinical criteria,

a list of example terms that represented the variable and a

list of example terms that might be considered but that do

not represent the variable. Please see Table 1.

Table 1. Examples of mental health references.

DSM-IV Criteria for Depression Examples of Key Words/Phrases Don’t Include:

Depressed mood Sad, empty, crying, tearful, alone, lonely, sad face emoticon“I had a bad day”, “FML”

Decreased interest or pleasure in

activities Not having fun, do n ’t feel like doing anyth in g , giving up

Increase or decrease in appetite No appetite, don’t feel like eating, can’t stop eating,

eating everything i n sight

“I ate too much at McDonalds this weekend”,

references to poor eating habits rather than

changes in appetite

Sleep problems Sleeping too much, slept more than 10 hours, fatigue,

tired, exhausted

Psychomotor agitation or

retardation Pacing, repetitive behaviors, feeling slow

Loss of energy Can’t get anything d o n e , no motivation

Feelings of guilt, worthlessness,

negative self-appraisal Feels guilty or worthless, “I’m so stupid”

Indecisiveness Can’t decide on something, don’t feel like deciding,

can’t ma ke u p mind

Recurrent thoughts of death or

suicidal ideation Thinking of ways to commit suicide, references to

jumping

Difficulty concentrating Can’t study, can’t finish work, can’t concentrate Don’t want to concentrate, can’t concentrate

because of activity (TV, friends, Facebook)

M. A. MORENO ET AL.

188

We then established details of the protocol. These in-

cluded in what time period the profile should be evalu-

ated. For example, many profile owners have had a

Facebook profile for several years; investigators using

the codebook would need to know how far back in time

to conduct a profile evaluation. The codebook protocol

also included instructions regarding which comments on

the SNS profile should be evaluated (comments from the

profile owner only versus comments from other users

that have posted on that profile owner’s wall).

The codebook data collection sheets were then out-

lined. The data collection cells were designed so that

sections of the profiles (i.e. information section, profile

wall) would be evaluated in the same order each time a

participant’s profile was coded. Variables in the code-

book were presented in the codebook in the same pre-

scribed order that the coder follows during the profile

evaluation process .

2.5. Codebook Layout

The codebook was initially designed in Microsoft Ex-

cel®. Excel data sheets allowed separation of layers of

the codebook onto several separate excel sheets within

one excel file. The layers included the following: 1) the

codebook protocol and coding criteria, 2) the data collec-

tion sheet with variables on the horizontal axis, allowing

for participant data to be entered across each individual

row, 3) the form for coders to track questionable refer-

ences to discuss with the team, as well as document the

outcome of the team’s discussion regarding those refer-

ences. Table 2 includes an example section of a data

collection sheet including demographic information and

references to depressive symptoms.

2.6. Coding Procedure

Coders follow several steps with each profile that is

evaluated. First, the “information section” of the profile

is viewed to obtain demograph ic information. Second, to

evaluate depression symptom disclosures, investigators

review each profile’s status updates from the predeter-

mine d s tar t d ate up through the current date of evalu ati on .

Each status update is evaluated. For each status update

that includes a depression symptom reference, coders

assess whether the displayed symptom meets one of the

DSM-IV criteria for a MDE [4]. If the displayed symp-

tom meets criteria, the coder recorded the date of the

disclosure, verbatim text and the depressive symptom in

which the verbatim text was correlated. The next status

update is then evaluated.

2.7. Adaptation of the Codebook

The initial depression codebook was designed to be ap-

plied to Facebook profiles. Over time, our research in-

terests have included evaluation of Twitter pages given

the rise in popularity of this SNS [30]. For each adapta-

tion of the codebook, the same iterative process is ap-

plied including application of relevant clinical criteria,

development of an initial set of keywords to apply to

profiles, evaluation of a practice dataset, and discussion

with the team to further refine the codebook. We con-

tinue to routinely communicate with our IRB and re-

search ethics colleagues to maintain the highest standards

of integrity in our data collection and reporting ap-

proaches. Further, we have examined applying our code-

book to other data storage systems such as Filemaker©.

We have found that using software like this is particu-

larly helpful when recording longitudinal data or larger

sample sizes.

2.8. Coder Training

The training of coders who will use the codebook follows

a similar process that was used in codebook development.

Coders are first trained in the ethics of human subjects

research, and provided additional training in the impor-

tance of confidential procedures in SNS and mental

health research. Second, coders learn the theoretical

foundation and diagnostic criteria that underlie the vari-

ables of interest. Coders are then trained to use the code-

book through several hands-on sessions in which coders

practice evaluation of profiles and active participation in

discussion is encouraged. After these sessions, coders

begin applying the codebook to practice sets of profiles.

Coding is first done with a mentor to provide real-time

feedback, and then practiced alone with a review of cod-

ing afterwards with that same mentor. Coders are en-

couraged to take their time to fully understand the proc-

ess of profile evaluation and the theoretical basis under-

lying the codebook. Coding training can last up to 3

months before coders participate in a formal research

project.

Interrater reliability is a critical parameter for the cre-

dibility of the codebook. Our procedure includes selec-

Table 2. Example of a data collection page in the codebook.

PPT ID CODER

INITIALS DATE GENDER AGEDepression symptom

Date 1 Depression symptom

Text 1 Depression symptom

Type 1

001 CK 10/12/12 F 20 10/5/12 Hate my life… 1,2

002 CK 10/12/12

M. A. MORENO ET AL. 189

ting a 20% random sample of profiles to be evaluated by

all coders. This process is done approximately every 2

weeks during coder training, and can be used to identify

individual items in the codebook that are vague or need

clarification. It can also be used to identify coder trainees

who would benefit from additional training. During each

research study, interraters are assessed at specified inter-

vals. Cohen’s Kappa statistic is used to evaluate the ex-

tent to which there was overall agreement in the coding

of the presence or absence of depression symptom refer-

ences on a profile. In our previous work, Cohen’s kappa

was 0.79 for depression symptom references [5].

3. Special Concerns

In the coding of health behaviors on SNSs, there may be

instances when concerning displays are identified which

suggest that the profile owner’s safety is at risk. It is

critical to determine your research team’s approach to

how such concerning disclosures will be handled, and to

train coders so they are prepared to deal with worrisome

situations that may become apparent when coding. In

coding depression, suicidal ideation or threat was a major

concern for our group. In response to this concern, we

developed a suicide protocol to manage any suicidal ref-

erences that may arise.

In developing a response protocol for any specific area

of mental health, it is advisable to first identify what ma-

jor areas of concern may be encountered while coding

this behavior. Examples may include suicidal ideation, or

disclosures of abuse or neglect. Second, the times in

which it may be crucial to intervene if such disclosures

are noted must be designated. This is important because a

worrisome disclosure may be time stamped anywhere

within the last week to one year ago. Third, a plan re-

garding how a coder will respond if these issues are pre-

sent must be developed. This intervention may be in the

form of a phone call, email, or text message sent by the

coder, the principal investigator, or another designated

person. The coder may be asked to provide mental health

resources, or alert appropriate authorities. Last, this plan

must be readily available to all research team members.

A brief outline of an example protocol is available as

Figure 1.

4. Discussion

4.1. Codebook Successes and Challenges

Our codebooks have undergone considerable adaptation

over the past five years. The iterative process has con-

tributed to adapting codebooks to account for new vari-

ables of interest as well as new trends and structural

changes among SNSs. However, this ongoing process of

codebook development has required time, patience and

team commitment. Development and maintenance of a

codebook leads to challenges inherent in team research:

the need for coordination of schedules and tasks to ac-

commodate frequent meetings, the time required to reach

group consensus. The time required in training a new

team member as a coder is substantial, when a team

member needs to periodically or permanently relinquish

their involvement in projects this can impact the overall

productivity of the team.

Another challenge has been adapting to changes within

SNSs. One example was changes in Facebook layout in

2011. During an ong oing study, we found that the layout

of Facebook changed to a “Timeline” format and addi-

tional types of information were added, such as a “cover

photograph.” This led to modifications to our codebook

Code

•R eference found on profile, ie. " going to end it all, "writing to s ay goodbye", "ready to

jump off a cliff"

Contact

•I f reference is displayed in p ast 2 days-phone and alert medical personnel

•I f reference is in pa st 30 d ays and recent displays are not worrisome-email/sns

message

•I f reference is greater than 30 days old-review wit h team to decide if contact is needed

•Make a plan to deliver necessary care, can have participant or assist part icipant in

contacting: crisis hotline, family member or friend, and/or couselingservice

Care

Figure 1. Key elements of suicide protocol.

M. A. MORENO ET AL.

190

determine how best to consider newly available data in

our assessments. Further, upgrades to SNSs can lead to

server outages and changes in how search engines func-

tion within the website, which may impact access to

Facebook as well as challenges in locating particular

profiles.

A final challenge has been adap tation to the social and

cultural norms that are found in a particular study popu-

lation. These norms contribute to behavioral expectations

defined with a group and are often present on SNS. For

example, a challenge for coders may be to interpret ref-

erences that may be meant as sarcasm in a certain social

group, or may have an unclear context from an outsider’s

perspective. Providing a systematic way to address these

questions by discussions and group consensus is a key

strategy, but requires time and scheduling. Additionally

cultural norms about mental health, for example, may

affect a particular culture’s display of depression symp-

tom references on SNS. Certain cultures may be im-

pacted by social stigma in that culture against displaying

any signs of mental illness. This may be easier to acco unt

for if the investigators conducting the coding are from

the same social or cultural demographic of the owners of

the profiles, however this is not always be possible. It is

important to be able to identify these social and cultural

norms and consider how they may affect the displays

being evaluated. Our team has found it particularly bene-

ficial to have input from people in the demographic being

studied as contributors to codebooks and partners in in-

terpretation of data.

4.2. Future Codebook Developments

Despite these challenges, our codebook development

process has been both rewarding and beneficial. We will

continue to revise and adapt our codebook as new re-

search questions arise and new trends in social media use

emerge.

This paper has focused on development of depression

coding criteria based on clinical standards. This stan-

dardized approach can be applied to the development of

codebooks for other areas of mental health towards

achieving a consistent and reliable assessment tool. An

example of the application of this codebook development

method includes developing a codebook to evaluate cog-

nitive vulnerabilities, previously applied to diary entries

[31]. The cognitive v u lnerab ility co d ing ap pro ach or co n-

tent analysis of verbatim explanations (CAVE) was de-

veloped in 1984 by Seligman and colleagues [32]. The

coding approach assesses cognitive vulnerabilities which

may be a precursor for depression symptoms [33]. In this

coding approach, each text disclosure is examined for

both an event and attribution, which are then categorized

as internal versus external, global versus specific, and

stable versus unstable. The text disclosures describing a

more internal, global, and stable state are considered

more indicative of depression. After applying the steps

outlined in this paper, our team recently pilot-tested this

coding approach on status updates on Facebook and

tweets on Twitter. We encountered challenges in identi-

fying status updates and tweets that included both an

event and an attribution due to the text references being

short in length and lacking detail, but we were able to

apply this coding scheme to a small percentage of status

updates and tweets on both sites. This example illustrates

how other content analyses strategies can be adapted to

SNS codebooks following the steps outlined in this pa-

per.

4.3. Future Research Approaches

We believe that SNSs may provide new opportunities to

increase student help-seeking behavior. It is possible that

such screening could be triggered by the content of a

SNS profile. When Facebook users view their profile,

advertisements triggered by keywords present on the

profile are displayed at the side of the profile. It is possi-

ble that university counseling centers could link mes-

sages about counseling services or links to online scree-

ning to keywords such as “depressed” or “hopeless”.

There are reasons to believe that online counseling may

be an acceptable approach in this digitally savvy genera-

tion, a recent study evaluated an interactive web-based

program designed to screen students for depression and

suicide risk. After the initial online screening, 24% of

students entered into an online dialogue with a counselor,

19% later attended an in-person session with the coun-

selor and 14% entered a treatment program [34]. SNSs

may provide an innovative venue to provide access to

online scre ening and follow-up re sources.

Given the difficulty in identifying students at risk for

depression, and the potential negative consequences of

untreated depression, is it imperative to embrace innova-

tive public health opportunities to reduce the burden of

mental illness in this population. However, any SNS in-

tervention ideas hinge on designing programs that are

acceptable to students and respect their privacy and con-

fidentiality [35,36]. Mental health disclosures are per-

sonal and potentially stigmatizing, thus, proper attention

to privacy will be essential. However, there are reasons

to be optimistic that today’s college students may wel-

come online mental health progr ams. A study assessing a

web-based intervention program found that among stu-

dents with an un-met need for mental health care, over

90% reported interest in or intention to use the program

[37].

In conclusion, it is our hope that this paper will pro-

vide detailed information about one systematic approach

to mental health codebook development so that other

researchers may use this structure to develop and test

M. A. MORENO ET AL. 191

their own codebooks for use in mental health SNS re-

search. It is not our intent to present this paper as the

only way to develop or use a codebook; rather, we hope

to assist other researchers in adapting this process to fit

their own areas of interest.

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