Facebook Use and Negative Behavioral and Mental Health Outcomes: A Literature Review

The purpose of this study was to review research that is associated with Facebook use and negative behavioral and mental health outcomes. Facebook was chosen over other social media due to its widespread use, significant influence on peoples’ lives, and increased research attention. A total of 22 articles met the inclusion criteria and were selected for this paper. Facebook use was associated with four mental health domains: Facebook addictionintrusion, depression, anxiety, and other mental health outcomes. This review emphasized the importance of improving measurement validity through the development of more consistent and complex Facebook use measure instruments.


Introduction
The way individuals interact and communicate has dramatically changed since the advent of Social Networking Sites (SNSs). They are not only popular among individuals, but also businesses. For instance, by 2016, 46% of the world population had access to and used the internet, with 31% being active social media users and 51% possessing a smartphone [1]. When it comes to social media, Facebook is by far the most popular form of social networking. In 2016, it had more than 1.71 billion active users per month, with 1.1 billion log-ins every day [2]. Facebook is also widely used among adolescents, with more than 71% of the users being between 13 and 17 years old.
General opinion about Facebook can be polemic; while some attribute advantages to it, such as increasing connectivity, sharing ideas, facilitating learning, and providing social support [1,3,4], others see it as an addictive cyberspace that can damage personal interactions. Given its popularity, and advancements in SNSs and behavioral health research, scholars coined terms such as Facebook intrusion and Facebook Addiction Disorder (FAD). In fact, the literature defines Facebook addiction (also Facebook intrusion) as an excessive attachment to Facebook that frequently causes problems in every day social functioning [5]. Indices of Facebook addiction include thinking about Facebook when not using it; becoming distressed when not being able to access it; and being unable to reduce time spent on Facebook [1,6]. The literature has indicated that some of the negative outcomes associated with Facebook usage are feelings of isolation, problematic Facebook use, psychological distress, feelings of jealousy and dissatisfaction with intimate relationships, lower self-esteem, depression, anxiety, impaired general health, and decreased sleep quality [7][8][9][10][11]. More recently, a report on the impacts of social media in children and adolescents by the American Academy of Pediatrics (AAP), indicated that Facebook usage could lead to depression [12].

Study Rationale
The purpose of this study was to review research that associated Facebook use and negative behavioral and mental health outcomes. Facebook was chosen over other social media due to its widespread use, significant influence on peoples' lives [13], and increased research attention. Even though several studies have indicated the correlation between Facebook and mental and behavioral disorders, there is still lack of concrete evidence [4]. As mental illnesses are a significant cause of morbidity in individuals, and given the pervasiveness of Facebook usage, a causal relationship in future research could signal an important and broad health risk [14]. Therefore, it is essential to underscore the importance of continuous research on this topic. Given the dearth of literature reviews specifically addressing Facebook use and behavioral and mental health outcomes, this review will help shed light on the impacts of Facebook use on individuals' behavioral and mental health, so that future research and practice can develop successful strategies around healthy social media use.
total of twenty-two articles were included in this review. Table 1 provides a summary of each article.

Results and Discussion
This section comprises the review of studies' outcomes, limitations, and future research recommendations. There were four main mental health domains identified, that is, Facebook addiction-intrusion, depression, anxiety, and other mental health outcomes. Several of the selected studies addressed more than two variables related to the four mental health domains.

Facebook addiction and Facebook intrusion
One challenging aspect of evaluating this domain was the interchangeable use of the terms Facebook addiction and Facebook intrusion. Given that both Facebook addiction and Facebook intrusion had the same definition and symptomatology [5], this review will group them under the same domain. Facebook addiction-intrusion was addressed in thirteen articles. There were three articles that addressed it as mental health outcome, and ten articles addressed it as a predictor of poor mental health outcomes. There were eleven crosssectional studies and two longitudinal studies. Three studies concomitantly measured intensity of Facebook use and Facebook addiction or intrusion; and their findings suggested that intensity of Facebook usage could be a predictor of Facebook addiction [6,[15][16][17]. All thirteen studies revealed that Facebook addiction was associated with general impoverished wellbeing. For instance, Facebook addicted users presented lower self-esteem, evaluated their life less positively, and were fewer optimists [16].
Additionally, the literature sheds light on risk factors for Facebook addiction that go beyond intensity of Facebook usage. The findings show that narcissistic individuals could be at a higher risk to develop Facebook addiction [6,9,18]. Another important factor is that Facebook addiction was related to personality traits. For instance, extraversion, agreeableness, and conscientiousness presented significant negative correlation with Facebook addiction; while neuroticism presented a significant positive correlation with Facebook addiction [19]. Finally, other risk factors that predicted Facebook addiction were being single, having less involvement in physical activities, sleep disturbance, and depression symptoms [17].

Depression
Facebook use, Facebook addiction, and depression were addressed in three cross-sectional and one longitudinal study. In one study, findings showed that having depression symptoms was a strong predictor for Facebook addiction [17]. While two studies did not find correlation between Facebook use and depression [14,20], the longitudinal study found that Facebook addiction was significantly positively related to negative mental health variables including depression [6]. It is important to emphasize that two studies evaluated the association between general Facebook use in relation to depression [14,20] while Brailovskaia and Margraf [6] found positive association between Facebook addiction, depression and other mental disorders. That said, when evaluating not only depression, but also other mental health outcomes, general Facebook use and Facebook addiction should be understood as independent constructs [21]. In other words, while Facebook use per se might not be correlated with negative mental health outcomes, problematic Facebook use that was classified as addictive, was found to be associated with depression and other behavioral and mental disorders [6,7,16].

Anxiety
Anxiety was associated with problematic Facebook use in six crosssectional studies. For instance, generalized anxiety and social anxiety symptoms in adolescents and adults were associated with increased Facebook behavior, repetitive Facebook behavior, and Facebook addiction [6,9,22,23]. Interestingly, role conflict as a result of excessive Facebook use, was also correlated with Facebook-specific anxiety and social anxiety [24]. Another eye-opening point is that social anxiety symptoms showed a robust relationship with passive Facebook use, instead of interactive Facebook use. Such findings suggest that depending on how it is utilized, Facebook has the potential to be an important social sphere for social anxious individuals [25].

Other mental health outcomes
There were five cross-sectional studies that measured other mental health outcomes such as obsessive-compulsive disorder severity, relational dissatisfaction, impoverished sense of wellbeing, and distress [6][7][8][9][10]. Interestingly, Chen and Lee [8] explored communication overload and self-esteem as possible mechanisms that underlie the relationship between Facebook interaction and distress. Even though their findings revealed that communication overload did not significantly mediate the relationship between Facebook interaction and distress, it did link them in a two-step pathway through reduced self-esteem. Their analyses also indicated that instead of a direct negative relationship between Facebook interaction and self-esteem, the variables are linked indirectly through communication overload.

Methodological Problems
While these studies shed light on the negative impacts of Facebook use on behavioral and mental health, they come with limitations. Inconsistencies of measurement of Facebook use [26] as well as inconsistencies of terms that define Facebook related disorders, leaves one under the impression that concepts and definitions are scattered in the field. For instance, considering that addicted individuals tend to underestimate the level of their addictive behavior , one major limitation found in all studies was that data collection was selfreported. In order to mitigate underestimation of addictive behavior, physiological functions such as blood pressure and heart rate should be considered as potential physiological markers of Facebook addiction in future research [6]. Oppositely, the literature has also shown that selfreport questions may lack necessary specificity, thus leading participants to overestimate their time spent on Facebook [27]. Therefore, in order to meet the various nature of Facebook addiction and improve measurement validity, it's essential that future investigations develop more complex and consistent measurement

Implications
This review has demonstrated that Facebook use may impact on different behavioral and mental health domains. Thus, it has several implications for further research and practice. The most prominent implication is the need for education regarding the potential negative behavioral and mental health outcomes related to Facebook use. Besides education, there is the need for the exploration of this phenomenon in daily clinical practice. Through the development of screening tools, physicians and clinicians should document problematic Facebook usage. In addition, consistent with treatment approaches to other types of excessive behaviors, health professionals should inquire patients about their Facebook use and behaviors. That is particularly important when primary care physicians and mental health providers are treating adolescents with generalized anxiety symptoms [7,22]. More specifically, as the American Academy of Pediatrics (AAP) promote education related to risks of children and youth using social media, such as problematic social media use and Facebook related depression [12,[28][29][30][31] , it is strongly recommended that AAP update their social media recommendations to include the possibility of the occurrence of generalized anxiety symptoms with increased adolescent social media use [22]. Equally important, if Facebook use becomes problematic and starts to interfere with social functioning and mental health, reducing access to it could help manage use. Additionally, problematic Facebook use should be treated with interventions that address underlying loss of control as the primary intervention target [21].

Study Limitations
This study has limitations of its own. The capacity to synthesize study findings was limited due to inconsistent terms that define Facebook related disorders, as well as inconsistent Facebook use measures. Additionally, during literature search, several studies that employed the terms social media and Facebook interchangeably were excluded. Such articles might have contained important data that is not present in this review.

Conclusion
While this review helped clarify the negative behavioral and mental health outcomes associated with Facebook use, due to inconsistencies of measurement of Facebook use as well as inconsistencies of terms that define Facebook related disorders, one is under the impression that concepts and definitions are scattered in the field. That said, in order to meet the complex nature of Facebook related disorders, improve measurement validity, and achieve more concrete evidence that attest Facebook related disorders, it's essential that future investigations develop more complex and consistent measurement instruments.