Antisocial Media

February 9, 2021

Late in medical school, I remember reading on several occasions that increased levels of social media use have been shown to correlate with adverse mood symptoms – chiefly anxiety and depression – in adolescents, with female-identifying youth experiencing stronger and more deleterious effects from prolonged use of social media. At the time, my statistically-just-as-phone-addicted-as-each-of-you-reading-this self filed that away on the shelf of “depressing problems with modern society that I’m partially complicit in but powerless to fix unilaterally”, just before “global warming” and just after “accelerated fragmentation of attention due to the omnipresence of technology”. Social media didn’t seem so bad as I flit about the adventures of fourth year, touring residency programs nationwide in the winter before visiting friends and family in Europe and Africa post-match. Life was pretty great, so of course everyone needed to see evidence of how good things were. Right? There was nothing self-interested in subconsciously wanting approval for how great things were. Right?

Flash forward to the first 28-hour weekend call of intern year, as the solo intern on the pulmonary service. I was in that strange moment of the late afternoon where suddenly, after a flurry of activity on rounds and completing post-rounds work, I found myself alone in a small, windowless workroom lit by painfully stark fluorescent lights and the disconcertingly industrial blue of idle computer workstations. As I looked through my list of to-dos and contingencies, I realized there wasn’t much active for me to do or follow up on. And thus as the stress of being a new doctor on call began to abate, a certain loneliness emerged. With stark clarity, I realized that despite there being a gorgeous July day outside, I was to remain here for…another 16 to 18 hours? Could that even be possible? Reflexively, unthinkingly, I pulled out my phone and glanced at Instagram, seeing stories and posts flash by of friends kayaking, at the beach, going to breweries…generally enjoying a weekend in place of embracing the rather monastic life I’d agreed to by starting residency. A pang of jealousy snuck in, a brief desire for a life other than the one I’d made for myself.

Within moments, I reproached myself for having had such feelings, reflexive as they were. It took only the smallest speck of self-reflection to consider that I’m sure these patients and their families don’t want to be here, either…and you will be free to leave tomorrow morning, while they wait night and day for test results, treatments to take their effect, for news of a coordinated plan from the seventeen subspecialists who have visited over the past week…. And with a flash of clarity, I deleted the Instagram app from my phone and took a walk around the hospital floor. I don’t remember precisely what I did next – if it was like other shifts to come, I likely did some combination of wandering the hospital to find the friendly face of a co-resident, reading about some condition I’d encountered that day, wondering if 4 PM on a call day was too soon to take a nap (then having that daydream interrupted rather baldly by a the blaring beep of a page), and spending additional time at a patient’s bedside to provide updates, gather more history, or simply offer some companionship. Notwithstanding the precise details of what I did, any objective observer would likely consider it a better use of my time than sitting around and wishing I had someone else’s life, incapable of sustaining the perspective that yes, social media is everyone’s highlight reel, yours included.  

And so, Instagram stayed off my phone for the next six months. When I re-downloaded it in the midst of the dark loneliness of my first New England winter-while-on-an-inpatient-service, I told myself I’d come back to it with a renewed perspective and healthier disposition. For a time, that was probably true. I enjoyed a honeymoon period of re-connecting with more peripheral acquaintances and seeing people’s accumulated life updates over the past half-year in fast-forward. But inevitably, I found myself falling prey to the same behavioral patterns that had plagued me beforehand. It came as no intellectual surprise that an app designed to be addicting – with bright colors, constant interactivity superimposed upon a constant veneer of social comparison, and, of course, intermittent reward intervals – was no less addicting after a brief hiatus. My brain remained just as vulnerable to the habit-reinforcing effects of the daily dopamine micro-dosing of garnering attention for content I’d posted, responding to messages, and finding I had yet another notification just when the activity began to dull; my academic understanding of the principles underlying social media addiction made me no less vulnerable to its effects.

As residency crept along, I found myself implicitly grateful for those shifts in which I was so engaged I forgot I even had social media on my phone, in which my phone was a tool I used rather than a tool that used me. No time to even think about responding to social texts when merely seeing patients, responding to pages, calling consults, writing orders, and, of course, updating the discharge summary occupied all of my mental capacities. But of course, each day had its diastole, and in those moments, similar behavior patterns emerged, generally without conscious effort on my part. It was not all bad, of course. There is nothing inherently wrong about chuckling at a funny meme, getting a passive reminder that it’s a friend’s birthday, or trying a new restaurant because someone posted about it. The issue only arose when social media became a superficial crutch for reminding myself I had friends rather than a tool to connect with them in person, the fire that cast shadows on the wall of Plato’s cave rather than the sun that illuminated the truth.

I retained enough self-awareness to recognize this problematic use even as I shied away from reinstating the nuclear option. As the Trump administration’s assaults on human rights continued, I was finding social media to be a cathartic outlet for sharing my thoughts (/rants): “No, Plan B is NOT an abortifacient”, “No, guns do not make schools safer”, “Yes, structural racism exists and this nation was founded on white supremacy”, et al. When I needed to focus at home – study for a board exam, write a grant proposal, tutor a student, finish clinical documentation – I would throw my phone across the room, allowing myself to focus outside the hamster wheel of dopaminergic stimuli. And so I proceeded in this way, enacting measures to curtail my social media use without eliminating it entirely – but there were undoubtedly still countless moments of “oh I’m just picking up my phone to enter the two-factor authentication to log in to Epic but somehow now 12 minutes have passed and I’m looking at photos from my college graduation, however did we get here?”. To err is human.

Then, both gradually and all at once, SARS-CoV-2 became a household name and COVID-19 made the anodyne ideal of meeting up with friends an act of complicity with contagion. The shadows on the cave wall became the sunlight as my phone became my primary vehicle for facilitate any social interactions outside of masked-and-distanced conversations at work. A two-week stretch of vacation in April, planned to include a week crisscrossing Spain and a 28^th birthday celebration to boot, became the genesis of my Netflix subscription, the exodus of my in-person interactions with humans outside of my roommate, and the Leviticus of wondering how judgmental and ineffective it was to call people out for having large group gatherings and not wearing masks, however vindicating it felt.  

So for all its double-edge-swordiness, social media in peak COVID became a place of solidarity, of making new connections across the country, of seeing resident friends in New York get cheered on by hundreds of apartments’ worth of applause at 7 each evening, of reminding myself that the pandemic would not be forever. While my screen time undoubtedly increased (thanks for the incessant reminders, Apple), this was now the price of behaving safely and responsibly as a healthcare provider during a plague, so the act of staring at an image of a friend’s face rather than the face itself seemed less lazy.

And mercifully, I was not confined home for long – unlike so many others, I had the privilege of returning to work, and of continuing regular, meaningful in-person interactions with other humans even in the height of the pandemic. I watched the BLM protests from the relative safety of my Twitter feed, swirling with a complex mix of feeling solidarity with the cause while not wanting large gatherings to worsen the spread still further while reading with increasing hope the data that outdoor transmission of COVID was liable to be inefficient, particular with masks and distancing. Life relaxed somewhat as I allowed myself to walk around Jamaica Pond with a friend, to eat at opposite ends of a picnic blanket with another, to re-engage with those around me in ways that wouldn’t make me the next best vector of disease.

Inevitably, yet another winter arrives and the opportunities for outdoor socializing diminish. I am struck in parallel by the incessant stream of children I see in the Emergency Room and on inpatient units in psychiatric extremis: a girl who takes thirty times the prescribed dose of her antidepressant so that she’d fall asleep and never wake up again, a boy who attempts to strangle himself with a shoelace. A child with autism who cannot stop throwing objects in the home, whose parents admit they have not been able to re-create the delicate routines he had in school as they engage in the futile dance of balancing full-time parenting and full-time work (hint: this is impossible).

And thus I see the presentations for acute psychiatric needs in adolescence mount far higher than our cases of MIS-C, our inpatient wards filled with the sequelae of depression, anxiety, PTSD, and bipolar disorder rather than bronchiolitis, asthma, and gastroenteritis. As I ponder the underpinnings of this spike in psychic distress, I can’t help but think back to the studies relating social media use to adverse psychiatric outcomes. We have a nation of adolescents who have been told, rightly so, that normal socializing is a public health risk. They are faced with an awful choice: to ignore the recommendations of public health officials by continuing to meet up as normal, or to behave in a socially responsible way by staying home while they see their friends post photo after video after photo as though there’s nothing so novel about this coronavirus. The exposure to – and isolating effects of – social media have never been more potent, and I simply cannot envision that this is not contributing to the surge we’ve seen in exacerbations of anxiety and depression.

This piece is obviously reflection conjecture built on anecdotal experience, not validated data. But though I have neither p-values nor qualitative interviews to offer you, I have at least questions to pose to you: how has your social media use changed during the pandemic? Has it become more or less problematic? What about that of the adolescents you know? Could any of them use a reminder that they’re still loved, even though love looks different right now? Who, upon further reflection, in your circle could use some COVID-safe reminder that you still care about them, even if caring still means distancing, and the interaction is still virtual?

Maybe reading this is just your chance to make your phone a tool you use, not a tool that uses you. Maybe.