Hello and welcome. I'm Shereen Khan, Vice President of Operations and Strategy at Thresholds, Illinois' oldest and largest provider of community mental health services and social work expert for SMI Advisor. I am pleased that you're joining us for today's SMI Advisor webinar, The Role of Social Media and the Internet in Early Psychosis Intervention. Next slide, please. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illnesses. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patient. Next slide. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, one continuing education credit for social workers, and credit for participating in today's webinar will be available until January 30, 2023. Next slide. Slides from the presentation are available in the handouts area, which is found in the lower portion of your control panel. You can select the link to then download the PDF. Next slide. Please feel free to submit questions throughout the presentation by typing them into that question area, also found in the lower portion of your control panel. We will reserve 10 to 15 minutes at the end of the presentation for Q&A. Next slide. Now, I'd like to introduce you to the faculty for today's webinar, Dr. Michael Birnbaum. Michael Birnbaum, MD, is an attending physician in the Department of Psychiatry at Zucker Hillside Hospital in New York. He works as the program director for Northwell Health's Early Treatment Program, a clinical and research initiative for adolescents and young adults in the early stages of psychosis. Dr. Birnbaum's research has focused primarily on psychotic disorders with an emphasis on the early stages of the illness. He is currently exploring the role of social media and the internet and pathways to care for adolescents and young adults with psychotic disorders. Additionally, Dr. Birnbaum is exploring the utility of social media and the internet as a vehicle for timely identification, outreach, engagement, and care of youth with mental illness. Thank you so much, Dr. Birnbaum, for leading today's webinar, and I'll turn it over to you. Thank you so much for having me. It's a real pleasure to be here. I get to talk about some of my favorite subjects, including early psychosis intervention, the internet, and social media, and I will jump right into it. Here are my disclosures. Here are the learning objectives for today's talk, and an outline of what we'll be talking about today. Over the past two decades or more, I don't think it's an exaggeration to say that the internet has exploded and has drastically and forever transformed the way that we communicate and share and learn, and this is true about all of us, but this is especially true for young folks who are the highest utilizers of the internet and also happen to be at the greatest risk for the emergence of a psychotic disorder, which is why we're here today. As of 2022, according to Statistica, there are over 300 million active internet users in the U.S. This is a field that is by far dominated by young people, but older folks, 30 to 65, trail very closely behind, and upwards of 75% of adults 65 and older also have access to and use the internet regularly. When we look at teenagers, as of 2022, almost 100% of them say that they use the internet at least several times a day, and nearly 50% of them are saying that they are almost constantly online, which is quite remarkable. The digital divide at this point is closing, and these numbers hold up for the most part, regardless of race and ethnicity and age, and you may ask, what are all of these folks doing online? One of the most popular activities over the internet is social media. Social media was invented just over 20 years ago, and it is defined as any digital platform that allows users to create and share information. Since inception, there have been multiple different iterations of social media. There are now many different types of sites with lots of different features, and they're constantly evolving. In many ways, the type of social media that you gravitate towards is dependent on your age. For instance, young adults, 18 to 29, gravitate towards YouTube and Instagram, whereas older adults tend to gravitate towards Facebook. When we look at teens in particular, they tend to use YouTube, followed by TikTok, and most recently, a 2022 poll found that 95% of teenagers 18 and under are using YouTube in the US, and this is true regardless of whether or not you're a boy, you're a girl, you're black, white, Hispanic, you're a young teenager, older teenager, rich, poor, suburban, urban or living in a rural area, you are online connected. Nevertheless, adults say that they use their preferred social media account multiple times a day, at least daily, and on average, we're spending about an hour online on social media, and these numbers likely double, if not triple, when we explore other online activities beyond social media. So, clearly these platforms are ubiquitous. They are all over the globe, and therefore, they are incredibly powerful. There is a lot of potential here, and at the same time, they are highly controversial. Despite their potential, there are also some incredible challenges that are associated with the internet and social media, and globally, there are billions of active users every single day, so this has created amazing opportunities to connect, which can be both incredibly wonderful and also concerning. Some of the benefits that have been explored are cited here. One thing that the internet and social media can provide is enhanced communication. Ultimately, interactions that would normally end offline can continue in an online universe. Furthermore, social media sites, especially these days, have provided really special opportunities for young folks to develop skills, explore creatively, learn collaboratively. It's quite remarkable to see what they can do with music and videos and pictures by using these social media sites and the features that they allow. From a mental health perspective, the internet and social media has provided access to global communities, and this can be incredibly valuable, especially for marginalized and minority youth who might not otherwise feel a sense of belonging or emotional support that is so critical to healthy development. Furthermore, there's some research to suggest that young folks who are hospitalized, before they go to the emergency room, before they are hospitalized, they go online for advice, suggestions, support, guidance. Again, enormous potential for good and for bad. From a health perspective, we know that young folks are going online to obtain health-related information. Approximately 90% in a recent poll suggested that they go online to obtain health-related information. And beyond just information gathering, they're also downloading apps and using them for health-related issues. 61% suggested that they go online to view other people's stories, feel less alone, and hear other people's concerns. And there's even a minority, 20%, who have connected with healthcare providers. This is a beautiful foundation upon which we can build, including for individuals with first-episode psychosis. From a mental health perspective, we know that young folks are going online to obtain mental health-related information as well. In this same poll, about 50% of adolescents and young adults reported going online to obtain their mental health-related information. And these numbers are much larger if you're struggling with depressive symptoms. They almost double. And once again, including connecting with the provider. So young folks in the U.S. who are struggling with psychiatric symptoms, including first-episode psychosis, have the potential to connect with stories, information, and also potentially care. Among those who reported moderate to severe depressive symptoms, they also reported a greater likelihood of using social media to express themselves creatively, get inspiration from others, feel less alone, all things that could be potentially life-saving for some vulnerable youth. And if you're a young LGBTQ youth, you're more likely to use the internet to explore questions related to depression, anxiety, stress. And this is because the internet has really provided an anonymous and comfortable setting to gather information when it comes to issues that could potentially be stigmatizing, like sexuality, but also things like hearing voices and delusions and other experiences that young folks may not want to disclose. Concurrently, there's been a lot of research looking at the risks associated with social media. And in fact, the majority of the research, I would argue, has focused on the negative impact. And one thing that's been cited quite a bit is loneliness. Despite the internet's ability to connect us, we seem to be feeling increasingly alone, especially for folks who use a lot of social media. Furthermore, there's research to suggest that it could increase psychological distress, increase the likelihood of self-harm and suicidal thoughts and behaviors. There's also research to suggest that excessive social media activity can contribute to the development and exacerbation of psychiatric disorders. Youth can be exposed to inappropriate and offensive content, cyberbullying, online predators. Vulnerable youth can be exposed and influenced by radicalization, high-risk behaviors. Marketers certainly know exactly how to use these platforms. Somehow they always know what I need before I even need it or know that I need it, rather. There have been a number of theories to explore and explain the negative impacts that social media and Internet have on us and youth in the US. One dominant theory is the displaced behavior theory, essentially suggesting that we're spending so much time online on the Internet and social media that it's begun to interfere with developmentally appropriate offline experiences, that we are more sedentary, that this contributes to reduced face-to-face interactions that are necessary for healthy development. Also, our online activity could be contributing to sleep disturbances, ultimately exacerbating issues, psychiatric and emotional well-being concerns. Social theorists have suggested that social media in particular has influenced how people view themselves, how people maintain relationships and interact with others in a way that is detrimental to healthy development. And I believe that the Internet and social media in particular is the greatest amplifier. It could make the good better and the bad worse. Which is part of why it's so controversial. For instance, young folks who report depressive symptoms are more likely to experience the Internet in a negative way, to feel as though other people are doing better than them when they look online, to feel like they get less likes, less comments, to feel left out when they're using social media. And in fact, many adolescents describe an addictive quality, suggesting that it would be very hard for them to stop using social media and the Internet, even if they wanted to. So what does this have to do with early psychosis and how do we bring it back to the topic at hand? We know that young folks are online and we also know that this is the same age that early psychosis emerges. And so as part of an early NIMH funded clinical trial, we wanted to get a better sense of how young folks with early psychosis were using the Internet as illnesses, as psychiatric symptoms were emerging, but also throughout care. And we also wanted to know how we as mental health clinicians could better incorporate the Internet and social media to improve the work that we do. We interviewed about 344 participants, of which approximately 122 had first episode psychosis. And we learned, perhaps not surprisingly, that social media and the Internet are an important part of daily life for most individuals with first episode psychosis, much like their healthy counterpart. In fact, 90 percent of them reported currently using social media regularly, and they reported that social media and online activity predated illness onset and continued throughout care, which we thought was really interesting. And I'll go into in a little bit more detail in a moment. Youth with first episode psychosis reported checking their social media accounts multiple times a day, just like healthy youth, and spending on average two hours, just under two hours per day online. I was most excited by this finding, which was that the Internet really was a primary source of information gathering. In fact, youth said that they went online first before reaching out to parents and professionals and caregivers, and therefore the Internet really represents one of the first proactive steps towards help seeking, something that is really exciting. And I think that we have maybe the most benefit, the most potential when it comes to the connections that are available online. We also learned that young folks were comfortable and willing to share their digital data with us. And so we've been collecting their digital data for many years now. At this point, it's pretty well established that young folks with first episode psychosis have access to digital devices and they use them frequently. And we also know that acceptability and interest in online and social media based interventions is high. So despite the established efficacy of early psychosis intervention for individuals with first episode psychosis, multiple challenges exist. And for many of us, we believe that many of these challenges could be addressed using the Internet and social media. The challenge, of course, is figuring out ways of truly enhancing the benefits, focusing on the good and reducing the risks, reducing the challenges and the problems that are associated with use. One way that social media and the Internet is being explored is to provide objective sources of digital data, essentially digital X-rays. For those of you who may not be aware, these tech companies, Facebook, Twitter, Instagram, Google Store, for the most part, everything that's been said and done online since account creation, anybody can go into their settings and request their archive. And within a couple hours or a couple of days, depending on how active you've been, you get an email with your archive. It shows up as a file and it's quite eye opening to see what we were searching for, thinking about doing a year, two years and more in advance. Concurrently, there have been major advancements in our computational techniques, our ability to extract meaning from all of the noise. And at this point, online and social media data has become an established source for capturing information about a person and also a population. And the way that this is done is through explicit commentary, what people are writing online, but also in the subtleties of language, the grammar that people choose to use, the words that they choose to upload and the patterns, what they're liking, what they're sharing, what they're looking at. And from a public health perspective, this has become an established source for capturing information like the spread of the flu. You could literally see on maps the spread of the influenza virus as people are searching for runny nose, fever, cough. And this is true for seasonal allergies, HIV infection, cancer, smoking, obesity, Microsoft Research recently published a paper suggesting that they could predict they could identify pancreatic cancer a year in advance of the diagnosis based on what people are searching for in Bing. And Google Research not too long ago published a paper suggesting that they could identify the restaurant responsible for a foodborne illness outbreak based on geolocation and people's searches and their search history. From a personal perspective, perhaps not surprisingly, our patterns online can predict our personality, our intelligence, our mood, substance use, religious and political views with high degrees of accuracy. In many ways, our computers and our online activity knows us better than our closest allies. From a mental health perspective, this has been incredibly promising. The majority of the research so far has been done with computer scientists with limited input for mental health clinicians, although that's changing. And in a recent review article, here is an illustration of all of the studies done thus far that have successfully predicted psychiatric diagnoses based on online activity. And I'm going to talk about some of the stuff that we've done focusing on first episode psychosis. Our first clinical question was, what does relapse look like on the pages of Facebook? How does relapse manifest? First episode psychosis relapse manifest online. And the reason that we focused on this is because it's a big clinical challenge. Again, despite the established efficacy of early psychosis intervention care, relapse is common. Up to 80 percent of individuals have a relapse within the first five years. Each new relapse is associated with a reduced likelihood of returning to the way things were before. It makes it increasingly challenging to return to school, work, friends, family. And the way that we assess for relapse now is limited and flawed. It's essentially clinical interview, subjective self-report, family observation. There are no ways to objectively measure relapse in a timely way and in a way that is specific enough to pick it up as early as possible. That being said, we know that relapse doesn't happen overnight. There are subtle changes in sleep, mood, attenuated psychotic symptoms that bubble up. And so we wanted to know what this looked like on the pages of Facebook. This project was done in collaboration with Georgia Tech. Essentially, we extracted 52,000, just over 52,000 Facebook status updates. This is what people were actually writing on their profile pages across 51 individuals with first episode psychosis who had a relapse hospitalization. And we segmented the timeline, their archives, into periods of relative health and relative illness. The way that we did this is we said any month before relapse hospitalization was considered illness and any other month was considered relative health. We used a machine learning approach called anomaly detection, which essentially identifies changes in the relapse month, differences that are identifiable in the relapse month compared to healthy months. And we looked at language using linguistic inquiry word count. It's an established linguistic analysis software. And we also looked at behavior. And we found that in the month preceding a relapse hospitalization, there was a significant increase in swear words, in words related to anger, in words related to death prior to the hospitalization. We found that there was a significant decline in words related to work, friends and health, possibly associated with withdrawal that's associated or often seen in individuals who are having a relapse. We identified an increase in first and second person pronouns. For example, I, me, mine. First person pronouns in particular are relatively well established in the scientific literature and the linguistic analysis literature when it comes to schizophrenia, thought to potentially represent a self-referential focus that suddenly irrelevant neutral stimuli have an important meaning to me in particular contributing to delusions. We also identified an increase in tagging and a significant increase in friending, potentially disorganized or a manifestation of disorganized behavior. We then fed these features into a machine learning algorithm, a model that was asked to predict if Facebook activity, if we provided Facebook activity to the model, can it then identify if it belonged to a healthy month or a relapse month? And our classifier did well at predicting a relapse month. It struggled with sensitivity and it often incorrectly labeled a month that we had identified to be healthy as relapse. And so we tried to understand this. We went back into the medical record and we found that sure enough in about half of these instances, there were indeed symptomatic exacerbations. They just didn't necessitate a hospitalization. And so for example, one person stopped taking medicine and had a worsening psychotic symptoms. Another individual was admitted to a partial program, but they weren't hospitalized. And so now we are doing this prospectively. We're doing symptom rating scales as opposed to focusing on hospitalization. We have a much more accurate determination assessment for how young folks are doing symptomatically over time and also the potential association with online activity. Similarly, we did this with Google data. This was done in collaboration with some folks at Cornell Tech and Georgia Tech. Here we extracted 32,000 search queries from individuals with first episode psychosis who had a relapse hospitalization. And we found that in the month preceding a relapse hospitalization, young folks with first episode psychosis started searching less. When they did search, their searches were smaller. There were less words and the words that they use change. They were more likely to search with words related to perception, like hearing, seeing, feeling, more likely to search with biological process words like pain and death, blood, and less likely to search using words related to health. Now pivoting to a similar approach, but a different clinical question, we asked ourself, what does emerging mental illness look like on the pages of Facebook? How does our online behavior and activity change as symptoms are just starting to bubble up? And the reason that this is important is that in the US and really throughout the world, the duration of untreated psychosis is unacceptably long. The moment that symptoms begin to the moment that people finally get into care is much too long, allowing for a lot of damage to occur, psychosocial damage, and the duration of untreated psychosis has been independently found to be a predictor of worse outcomes. And so there are major global efforts to reduce the duration of untreated psychosis, to get people into care sooner. There's also some research to suggest that young folks may be missing a critical window of opportunity after which early psychosis intervention may not work as well. So what we did here is we extracted just over three million instant messages. These are personal private messages that individuals were sending each other, to each other on Facebook. We also extracted over 142,000 images that were uploaded on Facebook from individuals with first episode psychosis, mood disorders, and healthy volunteers. And we extracted 18 months before the hospitalization, the first hospitalization. This is a period of time before they were diagnosed, before it was brought to clinical attention. And we found that a year and a half in advance of the first hospitalization, young folks with first episode psychosis are already using more words related to perception, hearing, seeing, feeling. We also found that both folks, both individuals who go on to develop first episode psychosis and mood disorders are already using more swear words. And folks who go on to develop mood disorders were using more words related to biological processes than healthy volunteers. Here's an illustration of the statistically different differences that we found among the three groups. When we look at images, we found that again, a year and a half in advance of the hospitalization, individuals with both first episode psychosis and folks who go on to develop mood disorders are more likely to upload photos that are smaller in height and width, possibly being cropped. And we also found that folks with mood disorders were more likely to upload photos that contained more blues and less yellows. Here is an illustration of the size of the difference as we get closer to the hospitalization. So within each graph, towards where it says KS score on the left, that represents the hospitalization across the y-axis, and six trimesters further away from the hospitalization, 18 months in advance. And essentially, these are all Facebook features that are statistically different 18 months in advance and continue to get increasingly different as we get closer to the hospitalization, presumably as psychotic symptoms or mood symptoms exacerbate ultimately requiring hospitalization. And similarly, we asked ourselves, what does emerging mental illness look like on the pages of Google? This was done with Cornell Tech. We extracted a year's worth of Google data from individuals with first episode psychosis, mood disorders, and healthy volunteers. In total, we had just over 400,000 search queries. And we found that a year in advance already, there are important differences in language. Healthy individuals are using more words. They're more likely to use punctuation. And individuals with both mood disorders, or rather individuals who go on to develop or be diagnosed with mood disorders with first episode psychosis, are more likely to use first and second person pronouns. Folks who go on to develop schizophrenia spectrum disorders are more likely to use words related to perception, hearing, seeing, feeling. And folks who go on to develop mood disorders are more likely to use words related to negative emotion, sadness, and death. We also see that a year in advance of the first hospitalization, individuals who go on to develop both first episode psychosis and a mood disorder are searching about half as much as their healthy counterparts. And they're also more likely to be searching between midnight and 6 a.m., presumably when their healthy counterparts are sleeping. And we identified some subtle changes in language use, and also the timing of the searches as we get closer to the hospitalization. Again, as symptoms are presumably getting worse, ultimately requiring a hospitalization. When we look at the searches qualitatively, we found that many of them had clinical significance. There was one individual, for example, with a religious preoccupation, who was searching God dozens and dozens and dozens of times every single day before his hospitalization. There were also searches that provided clinical information that we were not aware of. For example, one individual was searching concerningly, how do I get a gun and I wanna blow up my school? Now, the next avenue that social media and the internet is being explored when it comes to first episode psychosis as a way to extend and enhance the benefit of early psychosis intervention. Unfortunately, in the US and for the most part throughout the world, early psychosis intervention is time limited, resources are limited. And on average, care is provided for about two years. Afterwards, people are discharged to treatment as usual. And unfortunately, many of the benefits that are observed during care don't persist post-discharge. There's also high rates of disengagement. And so there are efforts to mitigate and address this possibly by using the internet and social media. One innovative example is being spearheaded by Australia with some collaboration in the US, essentially a type of Facebook for individuals with first episode psychosis. They've created something that is termed or has been called Horizons. It consists of interactive educational digital modules where young folks with first episode psychosis can learn more about early intervention and self-help resources. There's also a peer-to-peer online social networking component, much like Facebook and Twitter and Instagram. And it's also moderated. They provide live support from a clinician, supported education and employment, and peer advocates. In the first randomized controlled trial, they gave individuals graduating from first episode psychosis care either treatment as usual in the community or treatment as usual plus this digital platform. And they found that at the end of the trial, those receiving Horizons were more likely to be in school and work, very important outcome. Also folks in treatment as usual were significantly more likely to visit the emergency room and trended to be hospitalized more than individuals receiving Horizons. Now the third and final way that the internet and social media is being explored when it comes to first episode psychosis care, and really I think the greatest potential is with help seeking. We know that young folks with early psychosis, with emerging psychosis are online searching for information but unfortunately the vast majority of them do not advance, at least not proactively or immediately. And to illustrate this, there was a team in California who was collaborating with Mental Health America, one of the largest advocacy organizations for mental health. One of the services that they offer is online screening and hundreds of thousands of individuals throughout the US complete a variety of screens on Mental Health America every single year, including the PQB which is a psychosis risk screener. And this paper was published in 2022. They were looking at data from 2017 from 120 individuals who completed MHA's PQB, the psychosis screener online. These are folks who proactively decided to complete a psychosis screener. Over 82% of them reported a distress score that was high that would typically warrant a clinical evaluation. And when these folks were asked what did they plan to do next with this information, about 50% of them said that they wanted more information. They wanted to discuss with a non-mental health professional or they wanted some additional online information. About 30% said that they would do nothing. And only 17% said that they would consider seeking care next. When we look at behavior as a more objective marker of intention, we see that only 8% went on to click for information related to treatment options or self-help resources when it comes to early psychosis. And only 1% initiated app-based professional supports and likely fewer of them actually made it to traditional clinical care. So there's a lot of work to be done here. Concurrently, this is a project, an NIMH funded clinical trial that just wrapped up. This was done in collaboration with Strong 365, which is an online resource hub dedicated to early psychosis. And the goal here was to develop and build a digital campaign that was designed to identify folks online, deliver a paid ad that looked much like a search result and bring them to a website. So essentially throughout New York State, if individuals or allies, caregivers, were searching for information related to early psychosis or mental health in general, they were offered a paid ad that looked much like a typical search result. Though we did this on Facebook and Instagram as well. And then when they clicked on the ad, they were brought to a landing page. The landing page looked like this. This was it. And we had three primary calls to action. Essentially one was to complete a mental health check-in quiz. The mental health check-in quiz consisted of questions geared towards psychosis, anxiety and depression. We pulled from symptom screeners and then we encouraged everyone to chat with a peer mentor, chat with a therapist or leave contact information and communicate with us via email or text. Throughout the, the campaign ran for a year. The clinical, the trial itself was 18 months. Throughout the year in total, we had just over 10,000 youth complete the quiz. This was a very popular activity among youth. So far we analyzed nine months worth of data and we haven't explored the entire data set just yet. But in the first nine months, we found that the folks who completed the quiz tended to be young, 18 and under for the most part. When we looked at the folks who we referred to care, including individuals with first episode psychosis, they tended to be slightly older. We think this is because an unfortunate obstacle we identified was parents, essentially teenagers reluctant to disclose to their parents and caregivers that they were struggling with psychiatric concerns and ultimately refused to advance, refused to engage, refused to referral and we weren't able to connect them with care even for young teenagers that would have benefited from care throughout New York State. When we asked them what they want, the vast majority said that they just wanted to learn about their emotional health followed by getting self-help resources. We of course were extremely invested in assessing everybody and referring them, but that was the last thing on their minds. Only 12% said they wanted a referral to care. And interestingly, the responses to the quizzes, the symptoms that are being presented impact the likelihood of stating a desired help-seeking activity. More specifically, folks reporting depression or anxiety were more likely to leave contact information as a more objective marker of help-seeking intention, whereas youth reporting psychotic symptoms were less likely to leave contact information. They were more likely to knock on the door and disappear. Youth reporting psychosis were also less likely to report a desire for a referral, unfortunately. And we noticed similar trends in allies who were completing these quizzes on behalf of somebody they loved. When we look at just the folks who reported hallucinations as a more, these are folks who are probably the most in need of a clinical assessment and evaluation, the vast majority of them didn't advance. Again, they completed a quiz and they just sort of disappeared. But some of them did leave contact information, and we believe this is, again, a more objective marker of an intention towards some form of help-seeking. And of those, we were able to finally assess and refer, or assess, rather, 46 of them. They were able to, they made it through the funnel to the assessment, and 25 of those were found to be experiencing psychotic symptoms. So again, the majority of folks online who seem to be interested in information and potentially early forms of help-seeking are not yet ready to take that major leap from assessment to, from information gathering to assessment and clinical referral. The real question that we were left with was can we advance help-seeking? Can the internet and social media be used to improve help-seeking for young folks with early psychosis? And we believe that the answer is yes. In total, we referred 365 youth with a variety of psychiatric disorders to mental health services throughout New York State. And we learned, in the first nine months at least, that the more assertive we were in our outreach, the more likely we were to result in a referral. We would text repeatedly until we would get a response. We also found that the quicker we were in our initial outreach, the more likely we were to result in a referral. When we responded immediately with a text, we were more likely to result in a referral. We also tested a variety of digital strategies to see if they would impact help-seeking and sure enough, some of them did. For example, we tested a follow-up form that was introduced post-quiz completion and we found that that increased the likelihood of leaving contact information by 25%. So we were really pleased by this. And in general, there was about a two-week dance that would go on over email or text with most of these individuals who were curious about mental health-related information but weren't sure what they wanted to do. And we would work on engaging them for about two weeks before we were finally able to assess and refer them. So where does that leave us and how do we incorporate all of this information into care? I think clearly these platforms are not going anywhere and they are only gonna become increasingly important, especially for young folks who are developing psychiatric disorders, including psychotic disorders. So it's critical that we introduce it and we figure out ways of incorporating it to care but it's incredibly complicated given the fact that it remains controversial and also it's dynamic. The platforms themselves are constantly evolving and first-episode psychosis itself is a dynamic illness with symptoms of exacerbations and relapses and changes that occur throughout care. We recently completed a questionnaire for individuals with first-episode psychosis. We called it SMILE, which is why you see that here. And we wanted to get a better sense of how young folks with first-episode psychosis are experiencing the world, both online and offline, without any assumption that one is better than the other, asking them where they felt more authentic, where they felt more judged, where they felt more connected, where they felt more accepted, where they were more likely to find love, make friends, find jobs, et cetera. And in the graph here, the darker the green, the more likely to get the response. And I just wanna highlight, I think the take-home message here is that the online universe and the offline universe, the boundaries between the two, I believe are becoming increasingly blurry and it's no longer okay to say that healthy behaviors happen offline and unhealthy behaviors are more likely to happen online. It's a new universe, a new world now, and we have to be able to figure out how we could effectively incorporate the world that's happening online with the world that's happening offline because it's equally as valuable and important. In order to, one way to incorporate into clinical care is through scales to get a better sense of how our young folks are using the internet and social media. I wanna emphasize that there are some scales that exist out there, but none of them yet really have a true nuanced appreciation for both the risks and the benefits. Most of them have this underlying assumption that that online activity is a challenge and a problem, something that needs to be addressed rather than nurtured. One thing that we can all do, and I try to do with folks in the early treatment program is to get a better sense of how much time they're spending online. This is relatively easy to do objectively. Anybody can look at a phone, and within settings, you can see how much time an individual is spending on all of their apps. This is one objective marker of online and social media-based activity. But in addition to time, we really need to track the impact. It's not just the amount of time that people are spending online, but what does it mean? How does it impact recovery? We want to get a better sense of what is good and what's problematic. The focus should not be on reducing time online or reducing social media activity, but rather tapering and replacing the things that are causing problems. There are certain features online that may be more prone to challenges, whereas others are helpful and can support recovery when it comes to socialization and other forms of online activity that are beneficial. And so these things we should really be encouraging and supporting. And also, especially for the young folks, the teenagers in particular, we should be involving the caregivers who often, I think, come with the expectation that the internet and social media is something that needs to be addressed and once again, reduced as opposed to supported. So questions I ask, what sites are you using? And not just what site, but what features. These sites are complicated and dynamic and evolving. And there are multiple different features available within each platform that can be used in a variety of different ways. And what are the pros and what are the cons? And ultimately, again, how does it impact recovery? So once I have a baseline assessment of how somebody's using the internet and social media, then throughout care, I really want to get a better sense of how it evolves and changes over time. How does one's perception of the online universe change? How does their behavior towards folks online change? Differences in engagement and response. Because these are just as critical, just as important, and just as meaningful and valuable as things that are happening in the offline world. And with that, I will stop and leave room for some questions, if there are any. Thank you very much. All right, thank you so much for that. So thanks for such an interesting presentation. And before we get into that Q&A, which as we mentioned, if you do have questions, please place them in that question box now. I want to just take a moment and let you know that SMI Advisor is accessible from your mobile device. So you can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating skills, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org slash app. So we have a couple of questions. One is that since youth, as you mentioned, are using the internet for information about their mental health issues, are there recommended resources for those with early psychosis in particular? Because there is so much information on the internet, are there certain websites in particular that they can both get education, but also then build community? So two forms of treatment, that education and then the normalization community for those who might have similar, be going through similar issues. Yeah, so yes. So taking a step back, the internet is full of wonderful resources, and it's also full of challenging resources and resources that are not giving the right message. And I think we have to be cognizant of that and also aware of the potential impact of what both the good and the negative can produce. To answer the question about what resources to recommend, there are some very good ones. I think NAMI has some great resources out there, WebMD, Strong 365 is one that I like a lot. And I know that OnTrack New York, that's a New York-based integrated network of first episode psychosis programs, are working on a community. They just recently launched something, and that's something that's going to evolve and grow, and hopefully will be able to expand beyond New York State. Certainly the internet allows us to eliminate boundaries in that sense. So at this point in time, I'm only aware of educational resources. I'm not aware of any formal opportunities for young folks with early psychosis to engage with each other beyond Facebook groups and other social media groups that have been spearheaded by individuals with schizophrenia and other psychiatric disorders. Those private groups do exist. But I don't know, I don't know enough about them to recommend them. And I think there are, last I checked, there were many. So this is a- Great, so let me just repeat the resource with the 365 at the end, I also- Oh, Strong 365, it's one that I like a lot. It provides a lot of great resources and information, especially for young folks with early psychosis and their caregivers. Great, thank you. So a question related to parents, right? So we talked a lot about how the clinician can engage somebody in talking about their usage, but do you have any recommendations or when parents might be a barrier, right? Because I think that parents now might see, just wanna be completely like no social media, no internet, especially for somebody who's struggling. So how do you recommend approaching this with parents? Yeah, I think that's a challenge and it's about building trust and it's also about providing education. I think that while parents may want to remove the phone and eliminate these outlets, it's also important to understand the potential value and benefit in having a community online and especially post COVID, the world exists over the internet these days. And I just wanna reiterate and I usually do to parents that it's not necessarily a negative to be online and it could be just as valuable and meaningful when it comes to recovery, finding a sense of belonging and being able to interact with other people who are providing support over the internet and not just the expectation that it needs to happen offline. The challenge is really getting a better sense of who and how, who the young individual is interacting with and how they're engaging with these platforms. And that's a process. One thing that I would encourage parents to do is let them use social media and the internet, let them use their phones, but initially do it under supervision so that it's not something that's happening in the dark. And once they're a little bit more comfortable, they can start providing a little bit more leeway and trusting their child to be using it more appropriately. That being said, of course, people have the potential to be exposed to things that are challenging and those are opportunities for education as well. And those are opportunities for learning experiences. And those are just the realities of the world these days, a connected world. I think just removing access to the internet is a band-aid and not a viable long-term solution. Thank you. Let's see. Let me see if we have any other questions. Okay. I think, so you talked about monitoring the usage and time spent and really how they're using it and if it's having positive or negative effects on them. Are there things that have been proven like specific activities online that have been proven to support early psychosis recovery? Not yet. And I think that's a really important question. As far as what features online, for example, or let me say that differently. There are interventions that have been explored like the one that I referred to before, Horizons. There are apps that have been developed that have demonstrated efficacy in supporting recovery, at least somewhat. But as far as using and leveraging existing platforms, not yet. We need a more nuanced understanding of how young folks with early psychosis are engaging with these platforms. And it's also a very personal experience. So I wouldn't wanna say that individuals who have a certain diagnosis engage in this way positively and this way negatively. I think this is personalized medicine. And the real question is how an individual uses these platforms for good and also when do the experiences make them feel bad? And it's a challenge, it's time consuming, but it's worthwhile to really spend some time dissecting this process and the experiences online because I do imagine that some folks may use the networking feature well, but may feel bad about themselves when they're scrolling through images. And so maybe the intervention is trying to reduce the time that they're scrolling through images and spending more time focusing on other features that are making them feel good. Great. Somebody was curious if the Horizon Intervention is still available or was that part of your research? The Horizon Interventions is a study. So it's not widely available unfortunately yet, but it's possible that things change in the future. Okay, great. Thank you so much for your presentation and for answering those questions. I'm just gonna move to a few final slides to wrap up now. So if there were any topics that were not covered in this webinar that you would like to discuss with colleagues in the mental health field, you can post a question or comment on SMI Advisors Webinar Roundtable Topics Discussion Board. This is an easy way to network and share ideas with other clinicians who participate in this webinar. 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social media

internet

early psychosis intervention

young people

benefits

challenges

research studies

relapse

emerging mental illness

online interventions