‘I don't know what led me to find your videos, but by some sort of luck I found your videos a month before I was diagnosed with schizophrenia. It's been a very hard and trying few months but you have given me a lot of hope. So thank you, keep up the good work.’
(Individual with schizophrenia commenting on YouTube)
‘I comment on many of these posts because if I give one person hope it is more than worth it to do so. Depression nearly cost me my life a couple of times when I was in my 20s. It was really very rough at times, I know there are many, many out there who want to give up but don't!!! THERE IS HELP OUT THERE! There are people who care!!!’
(Individual with bipolar disorder commenting on Facebook)
Posts like these on popular social media such as Facebook or YouTube convey acceptance, hope, validation and illustrate the give-and-take nature of connecting with peers online. Increasingly, individuals with serious mental illnesses like schizophrenia, schizoaffective disorder, or bipolar disorder are turning to social media to talk about their illness experiences, seek advice and learn from and support each other (Gowen et al. Reference Gowen, Deschaine, Gruttadara and Markey2012; Naslund et al. Reference Naslund, Grande, Aschbrenner and Elwyn2014; Miller et al. Reference Miller, Stewart, Schrimsher, Peeples and Buckley2015). This unsolicited communication occurs naturally and involves self-forming online communities of individuals who share an understanding of living with mental illness. Referred to as online peer-to-peer support, this emerging form of social interaction has been described as one of the most transformational features of the Internet (Ziebland & Wyke, Reference Ziebland and Wyke2012) and may present new opportunities to promote recovery, self-esteem and mental and physical wellbeing among individuals with serious mental illness.
Worldwide, serious mental illness is a leading cause of disability (Murray & Lopez, Reference Murray and Lopez1997) and is associated with debilitating symptoms of anxiety, depression and low motivation (Kessler et al. Reference Kessler, Barker, Colpe, Epstein, Gfroerer, Hiripi, Howes, Normand, Manderscheid and Walters2003). Being labelled mentally ill, and the ensuing societal stigma and prejudice, can have devastating effects on quality of life, self-efficacy and ability to pursue meaningful life goals (Corrigan, Reference Corrigan1998). For people with serious mental illness the effects of stigma, feelings of hopelessness and helplessness, and resulting social marginalisation and withdrawal lead to increased risk of substance use, poverty, homelessness, unemployment, hospitalisation and suicide (Dixon, Reference Dixon1995; Corrigan, Reference Corrigan2004; Folsom et al. Reference Folsom, Hawthorne, Lindamer, Gilmer, Bailey, Golshan, Garcia, Unützer, Hough and Jeste2005; Pompili et al. Reference Pompili, Lester, Innamorati, Tatarelli and Girardi2008). There are also numerous challenges to addressing these concerns from a clinical perspective. For example, to reach individuals with serious mental illness, it is necessary to overcome barriers such as social isolation, reluctance to use formal health care services and challenging social circumstances such as traumatic life events or disruptive home environments (RachBeisel et al. Reference RachBeisel, Scott and Dixon1999; Hert et al. Reference Hert, Cohen, Bobes, Cetkovich-Bakmas, Leucht, Ndetei, Newcomer, Uwakwe, Asai and Moller2011). Online peer networks may offer novel approaches for supporting and engaging this high-risk group in treatment efforts.
By early 2015, over 2 billion people globally had active social media accounts (Kemp, Reference Kemp2015). Social media refers to interactive web and mobile platforms through which individuals and communities share, co-create, or exchange information, ideas, photos, or videos within a virtual network. Online social networking represents a prominent form of communication in many people's lives. For individuals with stigmatised illnesses, such as serious mental illness, social media may make it possible to connect with others who share similar health conditions and to seek or disclose health information without having to reveal one's personal identity (Berger et al. Reference Berger, Wagner and Baker2005). Additionally, many people with serious mental illness experience symptoms that interfere with socialising in face-to-face encounters (Dickerson et al. Reference Dickerson, Sommerville, Origoni, Ringel and Parente2001). Therefore social media may help to facilitate social connections among this group by overcoming obstacles such as stigma and mental health symptoms (Highton-Williamson et al. Reference Highton-Williamson, Priebe and Giacco2015).
Research suggests that people with serious mental illness are interested and willing to form connections with others through social media. A survey of young adults found that those with mental illness were more likely to express personal views through blogging, build friendships on social media and connect with people online who have shared interests compared with those without mental illness (Gowen et al. Reference Gowen, Deschaine, Gruttadara and Markey2012). Similarly, another survey found that adults with schizophrenia were as likely as adults without mental illness to form social connections online despite having fewer offline relationships, lower income and less Internet access (Spinzy et al. Reference Spinzy, Nitzan, Becker, Bloch and Fennig2012). In a qualitative study, popular social media appeared useful for allowing people with serious mental illness to feel less alone and to find hope and to support each other, and to share personal stories and strategies for coping with day-to-day challenges of living with a mental illness (Naslund et al. Reference Naslund, Grande, Aschbrenner and Elwyn2014). Other studies have found that online support groups, forums and chat rooms serve as important venues for discussing sensitive mental health conditions (Kummervold et al. Reference Kummervold, Gammon, Bergvik, Johnsen, Hasvold and Rosenvinge2002), and for disclosing personal experiences of living with schizophrenia or seeking and sharing information related to symptoms and medications (Haker et al. Reference Haker, Lauber and Rössler2005).
Despite this mounting evidence, limited attention has been directed at utilising these online networks to disseminate materials for mental health education or support, or to widen access to evidence-based services among these high-risk individuals. In this paper we present our perspective on how interactions among people with serious mental illness over social media, referred to as online peer-to-peer support, may afford important opportunities to advance treatment efforts aimed at promoting mental and physical wellbeing in this group. First, we consider the importance of forming social connections and the role of social media among people with serious mental illness. Then, we propose three areas where online peer-to-peer connections may have a profound impact for these individuals. These include challenging stigma, increasing consumer activation, and accessing interventions for mental and physical wellbeing. We carefully consider the potential risks associated with interacting with peers online. To conclude, we discuss important challenges ahead and recommend future research directions.
Online peer-to-peer support and mental illness
Prior studies have emphasised the importance of individuals feeling connected to others and sharing a sense of belonging to a group (Brewer, Reference Brewer1991). Identifying with a social group is believed to increase self-esteem and self-efficacy, and reduce uncertainty about oneself (McKenna & Bargh, Reference McKenna and Bargh1998). Among people with serious mental illness, connecting with similar others may contribute to better recovery, personal wellbeing and social integration (Davidson et al. Reference Davidson, Chinman, Kloos, Weingarten, Stayner and Tebes1999). Yet, for these individuals, identifying and reaching out to others poses numerous risks in the form of disclosure and potential disapproval, rejection, or negative attitudes (Link et al. Reference Link, Struening, Rahav, Phelan and Nuttbrock1997). Many people with serious mental illness also experience challenges with face-to-face communication due to impairments in cognitive and social functioning (Dickerson et al. Reference Dickerson, Sommerville, Origoni, Ringel and Parente2001). For someone with serious mental illness, the decision to reach out and connect with others to discuss personal health issues typically occurs at a time of increased instability and when facing significant life challenges (Perry & Pescosolido, Reference Perry and Pescosolido2015). Seeking support and social connection is therefore a critical point in the lives of people with serious mental illness, and the decision of who to reach out to may be detrimental in determining their path to successful recovery and wellbeing.
Through social media, people with serious mental illness can potentially identify similar others and experience benefits of group participation at their own convenience, while remaining anonymous and avoiding challenges associated with interpersonal deficits such as interpreting social cues or non-verbal communication (Mittal et al. Reference Mittal, Tessner and Walker2007; Highton-Williamson et al. Reference Highton-Williamson, Priebe and Giacco2015). Social media overcomes geographic boundaries and time constraints, and allows users to choose whether or not to actively create content, disclose personal health information, post comments, or passively view content posted by others. Research suggests that within an online network, both individuals who choose to share content or connect with different users, as well as those who choose to seek health information without interacting with others can experience important benefits (van Uden-Kraan et al. Reference van Uden-Kraan, Drossaert, Taal, Seydel and van de Laar2008; Mo & Coulson, Reference Mo and Coulson2010; Chung, Reference Chung2014). Compared with spontaneous face-to-face encounters, social media users maintain greater control meaning that they can choose their own level of engagement and the extent to which they interact with others. This may be especially important for people with serious mental illness because social media may help them overcome debilitating effects of their illness such as information processing challenges, increased social anxiety, or difficulties with social interaction (Schrank et al. Reference Schrank, Sibitz, Unger and Amering2010). On social media individuals with serious mental illness can choose whether to post content and how quickly to respond to comments, and can revisit conversations or seek greater clarity at their own pace. For someone experiencing mental health symptoms combined with fear of stigma and rejection, this added control through online communication may be empowering.
Social media also represents a user-driven environment, where individuals with Internet access through their mobile device or computer can have a voice and the opportunity to express themselves and connect to a larger online community. Online peer-to-peer networks represent a significant contrast to traditional biomedical or psychiatric approaches to mental health care. Many people with serious mental illness have had to fight against discrimination and injustice, and advocate for basic human rights and mental health care reform (Tomes, Reference Tomes2006). For this group, social media may serve as a platform through which many of these individuals can continue to challenge prejudiced societal views, question authoritarian medical practices and share positive attitudes and beliefs.
New opportunities through online peer-to-peer support
We take the perspective that when an individual with serious mental illness decides to connect with similar others online, it represents a critical point in their illness experience. These individuals are likely facing significant personal challenges, social isolation, or fears about how others will view them, which may prompt them to seek information or support online. In Fig. 1, we propose a conceptual model to illustrate how online peer-to-peer connections may afford individuals with serious mental illness opportunities to challenge stigma, increase consumer activation and access online interventions. Our conceptual model is informed by existing literature including studies of online communities and online support groups for mental illness as well as other patient groups with diverse health conditions, and suggests how individuals with serious mental illness may benefit from peer-to-peer interactions following the initial decision to visit an online community. As depicted in Fig. 1, the proposed opportunities do not necessarily occur in a sequential order.
Fig. 1. Conceptual model illustrating potential opportunities that may be available to individuals with serious mental illness after visiting an online community of peers.
Challenge stigma
When individuals with serious mental illness visit an online community they may be experiencing shame, uncertainty and feeling alone with their symptoms or illness diagnosis. These individuals may have fears about reaching out to others, driven by concerns about what other people will say or think and the possibility of rejection because of their illness (Link et al. Reference Link, Struening, Rahav, Phelan and Nuttbrock1997). When individuals with mental illness internalise discriminatory societal views and stereotypes, it often leads to negative consequences including diminished self-esteem and self-efficacy, and greater depressive symptoms (Corrigan, Reference Corrigan1998). Stigma impacts an individual's ability to carry out daily activities such as work or school, to pursue life goals and to seek necessary mental health care (Link et al. Reference Link, Struening, Rahav, Phelan and Nuttbrock1997; Corrigan, Reference Corrigan1998).
Online communities may serve as powerful venues where individuals with serious mental illness can challenge stigma through personal empowerment and providing hope (Lawlor & Kirakowski, Reference Lawlor and Kirakowski2014). Studies have shown that knowing that there are others facing similar concerns, frustrations and illness symptoms can be highly reassuring and can create a sense of belonging to a group (Harvey et al. Reference Harvey, Brown, Crawford, Macfarlane and McPherson2007). Young adults with mental illness report that one of the primary reasons for connecting with others online is to feel less alone (Burns et al. Reference Burns, Durkin and Nicholas2009), and popular social media allows people with serious mental illness to feel connected while gaining a sense of relief from knowing that others share similar experiences and challenges (Naslund et al. Reference Naslund, Grande, Aschbrenner and Elwyn2014). Research also suggests that true self can be expressed more easily within online networks because the anonymity of the Internet can shield from disapproval or fear of making mistakes (Bargh et al. Reference Bargh, McKenna and Fitzsimons2002). This is also important because self-expression may help protect against harmful effects of stigma (Bargh & McKenna, Reference Bargh and McKenna2004; Whitley & Campbell, Reference Whitley and Campbell2014). Therefore, individuals with serious mental illness may benefit from interacting with others through social media because they can be themselves without letting the challenges of their illness get in the way.
Coming out and disclosing one's illness to others is also an important approach for addressing stigma (Corrigan et al. Reference Corrigan, Morris, Larson, Rafacz, Wassel, Michaels, Wilkniss, Batia and Rüsch2010; Corrigan et al. Reference Corrigan, Kosyluk and Rüsch2013). Through online peer-to-peer communities, individuals with serious mental illness can connect with others with lived experience and openly disclose their own diagnosis while choosing to share positive stories of recovery and facts to challenge stigma and directly address widespread myths and misperceptions about living with a mental illness. Research suggests that marginalised individuals may benefit from feelings of empowerment, greater personal identity and pride by connecting with similar others online (van Uden-Kraan et al. Reference van Uden-Kraan, Drossaert, Taal, Seydel and van de Laar2009). The increase in confidence and sense of belonging gained through selectively disclosing to others online may even make individuals feel more comfortable disclosing their illness in face-to-face encounters (McKenna & Bargh, Reference McKenna and Bargh1998). As the number of online forums, blogs, or Facebook groups dedicated to empowering and supporting people living with serious mental illness continues to grow, it is clear that online communities will serve as valuable outlets for these individuals. Future research must establish whether online peer-to-peer support effectively challenges stigma and helps overcome social isolation among individuals with serious mental illness.
Increase consumer activation
Engaging with similar others online may prompt further interest in learning what to expect, how to cope and how to approach important health care decisions. As individuals with serious mental illness increasingly use popular social media to share experiences navigating the health care system, discuss the use of different medications and communicate about the importance of finding the right doctor (Naslund et al. Reference Naslund, Grande, Aschbrenner and Elwyn2014); these online networks may promote consumer activation and mental health care seeking behaviours. A recent study found that many people with mental illness were motivated to seek formal mental health care after first searching or discussing concerns with peers online (Lawlor & Kirakowski, Reference Lawlor and Kirakowski2014). It is possible that connecting with similar others through online networks may act as a catalyst for prompting individuals to seek formal care (Powell et al. Reference Powell, McCarthy and Eysenbach2003).
Learning about the experiences of others may help individuals feel at ease, know what questions to ask and know what to expect during a medical visit or hospitalisation (Lowe et al. Reference Lowe, Powell, Griffiths, Thorogood and Locock2009). Prior studies have shown that when someone learns about other people's personal experiences facing illness, they feel more confident and empowered in making their own health care decisions (Entwistle et al. Reference Entwistle, France, Wyke, Jepson, Hunt, Ziebland and Thompson2011). Research also suggests that many people will seek health information online following a medical visit where they felt dissatisfied or disagreed with the advice they received from their medical provider (Raupach & Hiller, Reference Raupach and Hiller2002).
Among people with serious mental illness who have access to medical care, research consistently shows that it is substandard (Wang et al. Reference Wang, Demler and Kessler2002). Peer-facilitated approaches to finding ways to better communicate with medical providers, to navigate unfamiliar health care environments and to take an active role during primary care visits may be important strategies for improving the quality of health care encounters (Bartels et al. Reference Bartels, Aschbrenner, Rolin, Hendrick, Naslund and Faber2013). Therefore, learning from peers through online networks may help individuals with serious mental illness realise that they can make their own health care decisions, and may help them become more empowered consumers by being better prepared for medical visits and being more proactive and assertive in their communication with health care providers. Further research is needed to determine whether seeking health information and learning tips and strategies from peers online can help individuals with serious mental illness feel more confident in their interactions with medical and mental health care providers.
Access to interventions for mental and physical wellbeing
As people with serious mental illness feel comfortable visiting online networks, there may be opportunities for these individuals to access interventions aimed at supporting mental and physical wellbeing. Interventions delivered through online communities could leverage mutual support among peers, and help promote treatment engagement and prevent study attrition (Alvarez-Jimenez et al. Reference Alvarez-Jimenez, Alcazar-Corcoles, Gonzalez-Blanch, Bendall, McGorry and Gleeson2014), and reach a wider demographic including individuals who may be reluctant to seek formal services (Naslund et al. Reference Naslund, Aschbrenner, Marsch, McHugo and Bartels2015b ). There may be opportunities to deliver flexible interventions that allow personalisation by catering to the different needs and preferences of members of the online community (Alvarez-Jimenez et al. Reference Alvarez-Jimenez, Alcazar-Corcoles, Gonzalez-Blanch, Bendall, McGorry and Gleeson2014). Interventions could be adaptive, by integrating feedback from peers within the network and making improvements to intervention design and delivery in real time. For instance, an intervention could iteratively incorporate new strategies or content suggested by community members based on the number of likes or positive feedback from others.
To date, the majority of studies of online networks among people with serious mental illness have involved survey methods, qualitative interviews, or content analyses of online discussions (Lawlor & Kirakowski, Reference Lawlor and Kirakowski2014). Few studies have collected objective mental or physical health outcomes over time, and only a handful of interventions have been delivered to individuals with serious mental illness using social media (Alvarez-Jimenez et al. Reference Alvarez-Jimenez, Alcazar-Corcoles, Gonzalez-Blanch, Bendall, McGorry and Gleeson2014; Naslund et al. Reference Naslund, Marsch, McHugo and Bartels2015c ). For example, the HORYZONS social networking intervention for first episode psychosis involves the delivery of evidence-based online psychoeducation enhanced by moderated peer-to-peer support within an online forum (Alvarez-Jimenez et al. Reference Alvarez-Jimenez, Bendall, Lederman, Wadley, Chinnery, Vargas, Larkin, Killackey, McGorry and Gleeson2013, Lederman et al. Reference Lederman, Wadley, Gleeson, Bendall and Álvarez-Jiménez2014). Preliminary findings show that young participants were highly engaged in the HORYZONS system, and found it safe to use and empowering, and reported that it helped them feel more socially connected (Alvarez-Jimenez et al. Reference Alvarez-Jimenez, Bendall, Lederman, Wadley, Chinnery, Vargas, Larkin, Killackey, McGorry and Gleeson2013). Recent studies of online psychoeducation interventions for bipolar disorder have also included moderated discussion forums to facilitate peer-to-peer support (Simon et al. Reference Simon, Ludman, Goodale, Dykstra, Stone, Cutsogeorge, Operskalski, Savarino and Pabiniak2011; Smith et al. Reference Smith, Griffiths, Poole, Di Florio, Barnes, Kelly, Craddock, Hood and Simpson2011; Todd et al. Reference Todd, Jones, Hart and Lobban2014; Lauder et al. Reference Lauder, Chester, Castle, Dodd, Gliddon, Berk, Chamberlain, Klein, Gilbert and Austin2015).
While these studies have been highly promising, there have also been mixed results. A randomised controlled trial of online peer support yielded inconclusive results regarding the benefits of online interactions among individuals with serious mental illness (Kaplan et al. Reference Kaplan, Salzer, Solomon, Brusilovskiy and Cousounis2011). However, these interventions have all been delivered through online environments developed specifically for the research studies. Using artificially created online networks may not be generalisable because these networks may lack the norms, dynamics and atmosphere of naturally occurring online communities (Lawlor & Kirakowski, Reference Lawlor and Kirakowski2014). Therefore, future studies should attempt to use naturally occurring peer-to-peer networks as observed on popular social media. It will be important to consider how formal interventions may alter peer dynamics within naturally occurring networks, and whether providing evidence-based services in this way might affect how individuals choose to interact with each other online.
Given the high prevalence of co-occurring mental and physical health concerns among people with serious mental illness (Sokal et al. Reference Sokal, Messias, Dickerson, Kreyenbuhl, Brown, Goldberg and Dixon2004), interventions delivered through social media should be aimed at promoting both mental and physical wellbeing. Efforts could support individual empowerment, social connection, skill building, psychoeducation and mental illness recovery, while simultaneously promoting healthy lifestyle such as quitting smoking, eating healthy, establishing a regular sleep schedule and getting exercise. Efforts in the general population include interventions on Facebook for weight loss (Napolitano et al. Reference Napolitano, Hayes, Bennett, Ives and Foster2013) and smoking cessation (Ramo et al. Reference Ramo, Thrul, Delucchi, Ling, Hall and Prochaska2015) among young adults, while emerging wearable technologies could afford opportunities for peers with serious mental illness to share exercise or personal wellness goals over social media (Naslund et al. Reference Naslund, Aschbrenner, Barre and Bartels2015a ). Delivering interventions for mental and physical wellbeing through social media appears highly promising, yet the success of future interventions will depend on whether skills learned in online networks can be applied to real world contexts (Alvarez-Jimenez et al. Reference Alvarez-Jimenez, Alcazar-Corcoles, Gonzalez-Blanch, Bendall, McGorry and Gleeson2014).
Risks of online peer-to-peer support
Online peer-to-peer connections are influencing the way people with serious mental illness experience their symptoms, find ways to cope and seek mental health care; yet, risks and concerns surrounding this emerging form of online communication must be carefully considered. For instance, there are risks inherent in obtaining advice from peers with unknown credentials. It is not always possible to confirm the reliability of what peers say to each other in an online network, and it is not clear how different content is perceived as trustworthy (Entwistle et al. Reference Entwistle, France, Wyke, Jepson, Hunt, Ziebland and Thompson2011). It is also possible that learning from the experiences of others online may lead to unrealistic expectations and greater anxiety or confusion about one's own condition (Ziebland & Wyke, Reference Ziebland and Wyke2012). However, research shows that many people who visit online networks are aware of the need to evaluate the suggestions and advice provided by others with caution, and also to assess whether the information posted by others is applicable to their own health concerns (Armstrong & Powell, Reference Armstrong and Powell2009, Schrank et al. Reference Schrank, Sibitz, Unger and Amering2010).
Social media also provides opportunities to form meaningful relationships with others, which can be beneficial, but also poses risks. Prior studies have shown that individuals can develop a dependency for online relationships (Caplan, Reference Caplan2003; Chung, Reference Chung2013), resulting in further challenges communicating in offline environments (Crabtree et al. Reference Crabtree, Haslam, Postmes and Haslam2010). Online networks may also contribute to greater social withdrawal and avoidance (Lawlor & Kirakowski, Reference Lawlor and Kirakowski2014). However, many individuals with serious mental illness may already be highly socially isolated before seeking connections with others online, suggesting that online networks may at least provide some form of interaction or group belonging. It is also possible that online peer networks may be the only potential way to reach the most socially isolated individuals.
Online interactions with peers can generally have a positive influence, though it is possible to discover online forums that support or promote self-harm and other unhealthy or destructive behaviours (Ziebland & Wyke, Reference Ziebland and Wyke2012). Additional risks may include exposure to hostile or derogatory comments posted by others, as well as online harassment. A recent review of online social networking among people with mental illness found limited evidence of such risks (Highton-Williamson et al. Reference Highton-Williamson, Priebe and Giacco2015), though research must explore whether individuals with serious mental illness are able to retain a sense of control over negative social encounters online, or whether negative encounters further exacerbate their mental health symptoms or contribute to reduced self-esteem. These risks are not unique to online environments, and it is important to acknowledge that individuals with serious mental illness remain at elevated risk of being victims of discrimination, abuse and violent crimes in face-to-face encounters in real world settings (Goodman et al. Reference Goodman, Rosenberg, Mueser and Drake1997, Lam & Rosenheck, Reference Lam and Rosenheck1998; Hiday et al. Reference Hiday, Swartz, Swanson, Borum and Wagner1999; Corrigan et al. Reference Corrigan, Thompson, Lambert, Sangster, Noel and Campbell2003). Therefore, the risks of connecting with similar others through social media should always be considered in light of existing susceptibility to risks posed by offline encounters. Overall, benefits of online peer-to-peer support appear to outweigh potential concerns, though sources of risk must be explored further to inform future research efforts.
Challenges ahead and next steps
When people with serious mental illness connect with online communities of similar others to learn, share and give and receive support, it challenges dominant societal views that this alienated group lacks the technical proficiency and ability to engage in meaningful social relationships through contemporary technological platforms (Parr, Reference Parr2008). Online peer networks challenge pervasive societal stigma and discrimination by giving diverse patient groups their own voice and opportunity for self-expression. As the use of popular social media continues to proliferate rapidly (Duggan, Reference Duggan2015), peer-to-peer interactions will increasingly become an important part of how people with serious mental illness communicate with each other.
Future research must carefully consider the mechanisms involved in online peer-to-peer connections that may be fundamental in supporting and promoting mental and physical wellbeing, as these potential behavioural mechanisms may be applicable across rapidly changing social media platforms. Future efforts must also explore whether potential benefits of online peer-to-peer support are accrued equally across income and ethnic groups. Despite promising trends of increasing social media use (Duggan, Reference Duggan2015) and access to mobile devices (Smith, Reference Smith2015) across all demographic groups, focused efforts will be necessary to reach the most isolated and low-income individuals with serious mental illness who may have greater symptom severity, lower education and who may remain disconnected or unable to access online networks. Mobile devices have become the primary method for accessing social media (Kemp, Reference Kemp2015), which facilitates access among low-income individuals who rely on their mobile devices for Internet access (McGrane, Reference McGrane2013).
Increasing mobile connectivity and use of social media are occurring even more rapidly throughout the developing world (Pew Research Center, 2014). As popular social media becomes an integral form of communication and social connection across low-income regions, there is similar potential to leverage the bottom-up and user-driven nature of these online peer networks to support mental health recovery, empowerment and to combat stigma. This may be especially important in fragmented health care systems in low and middle income countries where access to mental health services is limited and even non-existent (Patel et al. Reference Patel, Araya, Chatterjee, Chisholm, Cohen, De Silva, Hosman, McGuire, Rojas and van Ommeren2007). It is possible that the greatest gains in peer-to-peer connections among people with serious mental illness will be realised across low-resource settings.
We are at the beginning of what will likely be a significant shift in the way that people with serious mental illness can challenge stigma, seek health information and access interventions aimed at providing support and promoting mental and physical wellbeing. As this research area advances, it is essential to closely involve individuals with serious mental illness who are active members of online communities to inform efforts aimed at harnessing the use of online peer networks. There are also methodological challenges to surmount, such as determining the ideal approaches for evaluating multicomponent interventions delivered through online peer networks, and identifying strategies for collecting objective mental and physical health outcome measures to determine effectiveness and impact. As Parr (Reference Parr2008) points out, people with serious mental illness may experience greater social connectedness, feelings of group belonging and instrumental and emotional support from online peer-to-peer support, however these individuals still live in an offline world. Therefore, the true challenge that lies ahead will be to determine whether benefits of feeling less alone, learning from similar others and gaining confidence from interacting with peers online translate into tangible and meaningful improvements in recovery, employment, or mental and physical wellbeing that will be realised in the offline world.
Acknowledgements
This work was supported by a grant from the National Institute of Mental Health (Grant number: NIMH R01 MH104555) and by the United States Centers for Disease Control and Prevention Health Promotion Research Center at Dartmouth (Cooperative Agreement Number U48 DP005018). The funders had no role in the preparation of the manuscript or decision to publish. The authors report no competing interests.
Conflict of Interest
None.
