Table 1. Summary of included studies.
| Internet medium | Lead Author, year, country | Population (N, %female) | Aims, Objectives | Results, outcome | Outcome | Design,Quality score |
|---|---|---|---|---|---|---|
| General use | Carew, 2014 [27], Canada and USA | Internet users (28805; 64) | To investigate mental health information seeking online, and to identify differences within age groups and geographical location | A 200% increase in online activity regarding mental health was identified (between 2006 [baseline] and 2010). Adolescents were most likely to initiate conversation about depression followed by anxiety, alcohol, suicide, sexting and marijuana. Adolescents tended to discuss concerns through the use of personal stories. | Positive | Quantitative High |
| Casiano, 2012 [28],Canada | Canadian young people aged 12–19 (9137; 49) | To examine to association between quantity of media use and health outcomes in adolescents | No significant association between any form of media and suicide ideation (internet use OR 0.98, 95% CI 0.83–1.16) | Positive | QuantitativeLow | |
| Carli, 2014 [29], 11 European countries | School based adolescents in eleven European countries (12395; 55) | To explore the prevalence of risk behaviours (excessive alcohol, drug use, truancy etc.) and their association with psychopathology and self-destructive behaviours | Latent class analysis identified three groups of adolescents: high risk, including pupils who scored high on all risk behaviours; low risk including pupils with low frequency of behaviours and invisible risk. This 'invisible risk' group was found to score high on use of media and have similar prevalence of suicidal thoughts/psychopathology as ‘visible risk’ group. The invisible risk group were at significantly higher risk than the low risk group for non-suicidal self-injury (Relative risk ratio (RRR) = 1.40; 95% CI 1.13 1.84), suicidal ideation (RRR = 1.29; 95% CI 1.12–1.48) and suicide attempt (RRR = 1.22; 95% CI 1.22–2.35). | Negative | QuantitativeHigh | |
| Hagihara, 2012 [26], Japan | Young adults in Japan; Rate of suicide; | To examine the association between suicide-related searches and the incidence of suicide on young adults in Japan | Association between Internet suicide-related searches and the incidence of suicide in Japan (over 77 months): the terms "hydrogen sulphide", "hydrogen sulphide suicide", and "suicide hydrogen sulphide suicide" at (t-11) were related to the incidence of suicide among people aged in their 20s (P = 0.005, 0.005, and 0.006, respectively). | Negative | Quantitative Low | |
| Katsumata, 2008[30], Japan | Japanese high school students (590;49) | To investigate the association between the experience of using electronic media and suicidal ideation in Japanese adolescents. | Suicidal ideation was significantly associated with anxiety about not getting email replies (OR 2.06; 95% CI1.33–3.20), and searching online for information about suicide and self-harm (OR 5.11; 95% CI 2.43–10.71) and hurtful experiences on the web (OR 1.71; 95% CI 1.03–2.84) | Negative | QuantitativeLow | |
| Kim, 2012 [31], Korea | Korean middle and high school students (75066; 47) | To consider the association between internet using time for non-educational purposes and adolescent health | Internet non-users (NIU) and heavy internet users (HIU) were found to be high risk groups when compared with moderate internet users (MIU) on multiple mental health measures. Suicide ideation was significantly higher in HIU and NIU (females: HIU = 43.4%; NIU 25.8%; OIU 21.8% (P<0.001); males: HIU 26.4%; NIU 16.7%; OIU 13.6% (P<0.001)) as was rate of attempted suicide (females: HIU 13.9%; NIU 7.3%; OIU 5.2% (P<0.001); males: HIU 10%; NIU 4.9%; OIU 2.4% (P>0∙001)) | Negative | Quantitative High | |
| Mitchell, 2007 [32], USA | American internet users aged 10–17 (1500; 81) | To explore internet use and interpersonal interactions of youth reporting self-harm | Youth who self-harm engaged in more risky online behaviours than those who did not including using chat rooms (57% compared with 29%) and to have a close relationship with someone they met online (38% vs. 10%) | Negative | QuantitativeHigh | |
| O'Connor, 2014 [33], Northern Ireland | Adolescents in Northern Ireland (3596; 48) | To determine the prevalence of self-harm and associated factors | Self-harm was found to be associated with internet/social media as well as variety of other factors including exposure to the Northern Ireland conflict. In total 15% of girls and 26% of boys endorsed either the internet or social networking sites as factors that influenced their self-harm. | Negative | Quantitative High | |
| Robertson, 2012 [3], New Zealand | New Zealand adolescents (8; 88) | To describe an adolescent suicide cluster and the possible role of online social networking and text messaging as sources or contagion and obstacles to recognition of a potential cluster | These cases did not belong to a single school but were linked by social networking sites including memorial pages. This facilitated the rapid spread of information and made recognition and management of a possible cluster more difficult | Negative | Qualitative Medium | |
| Collings, 2011 [34], New Zealand | New Zealand adolescents (71; 79) | To describe the influences of media on suicidal behaviours, from the perspectives of young people. | Participants considered some interactive media supportive. 80% (n = 12) of those who used violent methods of self-harm had been exposed to suicide content via the internet before the incident | Both Positive and negative | Mixed MethodsHigh | |
| Duggan, 2012 [20], Canada | Scope and nature of self-harm content across various internet mediums | To examine the scope and nature of self-harm content across informational/interactive websites, social networking websites and YouTube | Results suggest that peer driven websites are accessed more often than professionally driven websites. Self-harm is strongly represented among social networking websites and YouTube evidenced by large group memberships and video counts. The search terms yielded 41 dedicated groups on Facebook with memberships ranging from 2 to 4,686. The same search yielded 206 groups on MySpace with group membership ranging from 2–1653. Searches on YouTube produced 2,290 videos. Characteristics of groups, videos and posters are described. | Both positive and negative | QuantitativeMedium | |
| Dunlop, 2011 [35], USA | Young people aged 14–24 (719) | To determine whether online news and social networking sites, expose young people to suicide stories that might increase suicide ideation | Online sources of information were quite common (reported by 59% of participants). Social networking sites were frequently cited as sources but were not linked to increases in ideation. However online discussion forums were associated with increases in suicide ideation | Both positive and negative | QualitativeLow/medium | |
| Internet addiction | Kaess, 2014 [36],11 European countries | School based adolescents in eleven European countries (11356; 57) | To investigate the association between pathological internet use, psychopathology and self-destructive behaviours | Suicidal behaviours, depression, anxiety, conduct problems and hyperactivity/inattention were significant and independent predictors of pathological internet use (Suicidal ideation coefficient 0.324, 95% CI 0.251–0.397, P <0.001; Suicide attempts coefficient 0.552, 95% CI 0.207–0.896, P = 0.001).This association is significantly influenced by country and gender. | Negative | QuantitativeHigh |
| Kim, 2006 [37], Korea | High school students in Korea (1573; 65) | To elucidate the relationship between internet addiction, depression, and suicidal ideation | Internet addiction scores were positively correlated with suicidal ideation in non-internet addicts, possible addicts and internet addicts (non-addicted r = 0.111, p = 0.001; possible addicted r = 0.147, p < 0.001; internet addicted r = 0.448, p<0.001) | Negative | QuantitativeHigh | |
| Lam, 2009 [38], China | Adolescents in china (1639;55) | To examine the association between internet addiction and self-harm | Moderately or severe internet addiction was associated with higher incidences of self-harm (adjusted OR 2.0, 95% CI 1.1–3.7). | Negative | Quantitative High | |
| Lin, 2014 [39], Taiwan | Taiwanese adolescents aged 12–18 years (9510; 52) | To examine the associations of suicidal ideation and attempt with internet addiction and activities | Internet addiction was significantly associated with suicidal ideation (OR 1.25, 95% CI 1.08–1.44) and suicide attempt (OR 1.59, 95% CI 1.29–1.96). Specific internet activities associated with increased and decreased risk | Negative | QuantitativeHigh | |
| Park, 2013 [40], Korea | Korean middle and high school students (795; 68) | To evaluate a)associations between problematic internet use and depression, bipolar disorder symptoms and suicidal ideation; and b) whether mood disorders mediate the relationship between suicidal ideation and problematic internet use | Presence of problematic internet use significantly associated with suicidal ideation (OR = 5.82, 95% CI = 3.30–10.26, p<0.001) as well as depression (OR = 5.0, 95% CI = 2.88–8.66, p<0.001) and probably bipolar disorder (OR = 3.05, 95% CI 0.96–9.69, p = 0.059). Problematic internet use was found to predict suicidal ideation (ß = 0.115, 95% CI = 0.052–0.193, p = 0.006). Conversely suicidal ideation was found to predict problematic internet use ((ß = 0.215, 95% CI 0.089–0.346, p = 0.006). Complex transactional relationship. | Negative | QuantitativeMedium/high | |
| Aktepe, 2013 [41], Turkey | High school students in Isparta (1897; 43) | To measure the prevalence of internet addiction and to detect related socio-demographic factors | The prevalence of possible internet addiction was found to 14%. A significant association between problematic internet use and self-harm was found (ß = 0.574, OR = 1.79, 95% CI 1.30–2.43, P <0.001). Adolescents with possible internet addiction were also found to have low levels of loneliness and high levels of life satisfaction. | Both positive and negative | QuantitativeHigh | |
| Messias, 2011 [42], USA | Students aged 14–18 years; (16124; N/A) | To investigate the association between excessive video game/internet use and teen suicidality | Teens who reported more than 5 hours a day of video game/internet use had a significantly higher risk of suicidal ideation (OR = 1.7, 95% CI 1.3–2.1) and suicide planning (OR = 1.5, 95% CI 1.1–1.9). Authors find a potential protective influence of low video game use compared with no use. | Both positive and negative | QuantitativeHigh | |
| Sources of help | Hetrick, 2014a [43], Australia | Melbourne high school students experience suicidal ideation; (21) | To investigate the usefulness of an internet- based CBT programme | Over the course of the intervention negative problem-solving orientation improved (t = 4.38, p < 0.0005) and students relied less on emotion focused coping strategies. Adolescents rated the problem-solving and cognitive restructuring modules as particularly helpful. | Positive | QuantitativeMedium |
| Hetrick, 2015 [44], Australia | Australian young people aged 15–24 (15) | To develop and examine the feasibility of an online monitoring tool of depression symptoms, suicidality and side effects | Results show that an online monitoring tool is potentially useful as a systematic means for monitoring symptoms of depression and suicidality, but further research is needed including how to embed the tool within clinical practice | Positive | Mixed methodsMedium | |
| Mar, 2014 [45] UK | Individuals age 16–24 who had experienced suicidal ideation (23; 96) | To explore youth consumer preferences for online interventions targeting depression and anxiety | Youth positively received the idea of e-mental health services. Noted preferences for services that are simple to use, interactive and include support through an online community. | Positive | Mixed methodsLow/medium | |
| Saulsberry, 2013 [46], USA | Adolescents screening positive for depression in primary care (83; 57) | To test an internet program for young people with depression | Participants demonstrated significant within-group decreases in depression and self-harm ideation (any thoughts of self-harm in previous two weeks 14.46% at baseline compared with 4.82% at 1 year follow-up) | Positive | QuantitativeHigh | |
| Barton, 2013 [47], USA | College students (106; 55) | Study examined responses to open-ended email vignettes from a fictitious friend exhibiting depressed, irritable or suicidal communications | Results indicate student’s preferences for solving fictitious peer problems personally rather than professionally. Patterns of help-giving and sex differences varied by condition | Both positive and negative | QualitativeMedium | |
| Whitlock, 2013 [48], USA | College students (14372; 43) | To examine the impact of questions regarding self-injury, suicide and psychological distress in a web-based survey on respondents | Less than 3% of individuals reported negative survey experiences. Individuals with relevant personal experience reported greater discomfort with the survey yet were also significantly more likely to report that it caused them to reflect on their lives | Both positive and negative | Mixed methodsHigh | |
| Social media | Belfort, 2012 [49], USA | Adolescents presenting to hospital with self-harm (1350; 75) | To describe key similarities and difference among adolescents who communicated their suicidality via electronic Vs. other means | Numbers of electronic communication of suicidality increased over time from 8.3% in 2005 to 55.6% in 2009. Patients who communicated suicidality electronically more likely to do so to a peer (67% compared with 7% of those communicating by other means). | Negative | QuantitativeLow |
| Cash, 2013 [24], USA | MySpace users aged 13–24 (64; 40) | To explore the ways in which adolescents use MySpace to comment on their suicidal thoughts and intention | Comments referenced a significant amount of hopelessness, despair and desperation. Adolescents use public web sites to display comments about their suicidal thoughts, behaviours and intentions. | Negative | QualitativeLow/medium | |
| Zdanow, 2012 [21], South Africa | Analysis of self-harm groups on Facebook | To analyse the representation self-harm on dedicated Facebook groups | Content analysis of two groups revealed glorification and normalisation suicidal behaviours. Potential for social networking sites to be used as a tool for the promotion and encouragement self-harm | Negative | QualitativeLow | |
| Sueki, 2015 [50], Japan | Young adult twitter users (1000; 61) | To examine the association between suicide-related tweets and suicidal behaviour to identify suicidal young people on the internet | Logistic regression analysis showed that tweeting 'want to die' was significantly associated with history of suicidal ideation (OR = 2.53, 95% CI 1.61–3.99) having a suicide plan (OR = 2.55, 95% CI 1.56–4.17) and attempting suicide (OR = 1.67, 95% CI 0.95–2.94). Tweeting 'want to commit suicide' was significantly related to history of self-harm (OR = 1.87, 95% CI 1.03–3.41), having a suicide plan (OR = 1.92, 95% CI 1.07–3.46) and attempting suicide (OR = 3.48, 95% CI 1.89–6.42). Having a twitter account and tweeting daily were not associated with suicidal behaviour | Both positive and negative | Mixed methodsMedium/High | |
| Forum | Baker, 2008 [51], UK | Users of self-harm discussion forums (10, 50) | To explore the accounts of young people who self-harm and use forums | Forums were used positively for support and communication. Some participants report a reduction in the incidence of self-harm | Positive | QualitativeLow |
| Barak, 2006 [52], Israel | Users of self-harm discussion forums (20, 75) | To assess whether the degree of forum involvement affected distress levels | Levels of forum involvement was association with lower levels of distress, however levels of distress did not improve over three months (F = 2.10; df = 2, 787) | Positive | Mixed MethodsLow | |
| Jonesb, 2011 [53], UK | Users of a self-harm forum built for research (77, 95) | To explore what young people who self-harm think about online self-harm discussion forums | Participants claimed to learn more about mental health issues from online forums than from information sites, find it easier to talk about self-harm to strangers than to family or friends and preferred to talk online than in person. | Positive | Mixed MethodsMedium | |
| McDermott, 2013 [15], UK | Analysis of forum posts | To use qualitative methodology to examine internet forums where LGBTc youth discuss self-harming | This methodology can address some research dilemmas by generating diverse samples and a different type of unmediated complex data. Online data can enhance understanding of hard-to-reach youth | Positive | Qualitative Low/Medium | |
| Owensb, 2012 [54], UK | Users of a self-harm forum built for research (77; 95) | To bring together young people who self-harm and health professionals online | The young people were keen to share their experiences and supported one another during crises. Health professionals did not actively participate in forums due to reported lack of confidence and concerns relating to workload and duty of care. | Positive | Mixed methodsMedium | |
| Sharkeyb, 2012 [55], UK | Users of a self-harm forum built for research (77, 95) | To use discourse analysis and the concept of face-work as a framework to understand interactions in a self-harm support forum | Use of a range of mitigation devices found suggesting that the young people orient a 'protective line' in their supportive interactions. This may enable a more trusting, open context for support. | Positive | QualitativeMedium | |
| Smithsonb, 2011 [56], UK | Users of a self-harm forum built for research (77, 95) | To explore how young adults became members and sustained membership in a self-harm support forum | Participants displayed expectations about appropriate ways of discussing self-harm, responses and advice. Participants were active in shaping interaction on the forums requesting input from moderators. | Positive | QualitativeLow | |
| Smithsonb, 2011 [57], UK | Users of a self-harm forum built for research (77, 95) | To investigate the nature of problem presentation and responses in an online support forum | Analysis highlighted the tendency to offer advice where it was not asked for and the mundane 'safe' nature of advice | Positive | QualitativeLow | |
| Whitlock, 2006 [16], USA | Analysis of forum posts | To investigate the prevalence and nature of self-injury forums, to explore the content, role and influence of discussion forums | Informal support was the most common type of exchange (28.3% of posts). Concealment of practice (9.1%), perceived addictiveness (8.9)and formal help-seeking (7.1) were also discussion themes | Positive | Mixed MethodsHigh | |
| Eichenberg, 2008 [58], Germany | Users of suicide discussion forums (164; 50) | To assess the assumption that suicide message boards are harmful. | Both constructive (e.g. help-seeking) and destructive (e.g. finding a suicide partner) motives were identified. A significant reduction in suicidal thoughts was found following forum use (effect size d = 0.72 (t [144] = 9.2; p < 0.01). Unable to directly infer cause. | Both positive and negative | QuantitativeHigh | |
| Franzen, 2011 [17], Sweden | Qualitative study of a Swedish-speaking web community connected to self-harm | To analyse how self-injuring men and women construct themselves as cutters | Two main interdependent discourses are identified within the web community: the 'normalising' and the 'pathologizing'. | Both positive and negative | QualitativeLow | |
| McDermott, 2015 [18], UK | Analysis of web-based discussions | To utilise qualitative virtual methods to investigate LGBTc youth web-based discussions about seeking help for suicidal feelings and self harming | Young people wanted assistance but found it difficult to ask for help and articulate emotional distress | Both Positive and negative | QualitativeLow/medium | |
| Sueki, 2012 [59], Germany and Japan | Users of suicide forums in Japan and Germany (301, 54) | To analyse the cross-cultural use of suicide forums in Japan and Germany | Factor analysis demonstrated two motives: mutual help and suicide preparation. Suicidal thoughts did not worsen with forum use and there was no difference in demographics, motives or effects of suicide forums between Germany and Japan | Both Positive and negative | QuantitativeLow/ medium | |
| Westerlund,2013 [19], Sweden | Analysis of young adult forum posts | To examine conversations about suicide on discussion forums | Most participants communicate based on a need to gain acceptance and understanding. However there was also exchange of suicide methods and encouragement to go ahead with suicide plans | Both positive and negative | QualitativeLow | |
| Website with suicide/self-harm content | Lewis, 2011 [25], Canada | Authors and users of self-harm websites (71; 79) | Examination of the content of non-suicidal self-injury web sites | Websites depict self-harm as an effective coping mechanism (92%), addictive (87%) and not always painful (24%). Almost all websites contained melancholic tones (83%) and several contain graphic imagery (30%). Overall it is suggested that such sites may normalize and reinforce self-harm | Negative | QualitativeMedium |
| Harris, 2013 [60], Cross cultural (UK Europe, Canada, Australia, New Zealand and others) | Self-selected users of self-harm websites (329; 92) | To explore the reasons people visit self-harm websites or forums; beliefs regarding these sites; how the use of such sites modulates self-harm and other impacts of these sites on the lives of those who use them | 65.6% of participants visited sites at least twice a week, 78.2% used sites to find information and 68.4% to participate in forums. Positive effects of website use such as gaining help and support and reduction in self-harm behaviours were reported by a large number of participants. However smaller numbers reported negative effects including worsened self-harm | Both positive and negative | Mixed methodsHigh | |
| Video/image sharing | Lewis, 2012 [22], Canada | Analysis of comments on YouTube videos related to self-harm | To examine viewers comments on non-suicidal self-injury YouTube videos and determine potential risks and benefits of such videos | Viewer’s responses to videos may maintain the behaviour with admiration of video quality (21.95%), message (17%) and up-loader (15.40%) common. Comments rarely encourage or mention recovery (<3%). Sharing experiences online is a strong motivator for viewers of self-harm related videos | Negative | QualitativeMedium/High |
| Grzanka, 2014 [23], USA | Critical discourse analysis of online videos | To investigate a mass-mediated campaign against a perceived increase in suicides among gay youth in America | Analysis of videos showed a neoliberal frame that places the burden of a 'better' life onto youth who are instructed to endure suffering in the interest of inevitable happiness | Both positive and negative | QualitativeLow | |
| Lewis, 2011 [10], Canada | Posters of self-harm videos on YouTube (100; 95) | To examine the accessibility and scope of non-suicidal self-injury videos online | The top 100 videos were viewed over 2 million times and most were accessible to a general audience. Viewers rated videos highly (M = 4.61; SD 0.61 out of 5.0) and selected videos as a favourite over 12000 times. Explicit imagery common (64% of videos) with many videos not warning about this content | Both positive and negative | Mixed methodsMedium | |
| Sternudd, 2012 [61], UK, USA Europe | Young people who self-harm (52; 87) | To examine reasons for, and reactions to producing/viewing self-harm images online | Informants reported effects images was alleviating rather than triggering. When interpreting statements about images 40% were positive and 25% were negative. To publish them was a way of sharing experiences with others and to give or receive help. Participants emphasised that the outcome of viewing these photos varies by individual and situation | Both positive and negative | Mixed methodsLow | |
| Blogs | Castrod, 2012 [62], Portugal and Brazil | Authors of Portuguese language blogs (11, 82) | Analysis of pro-anorexia blogs to systematize and categorize their characteristics, content and messages | Blogs can have negative consequences as a result of sharing harmful information about fasting, drugs, self-harm and suicide | Negative | QualitativeLow |
| Castrod, 2013 [63], Portugal and Brazil | Authors of Portuguese language blogs (11, 82) | Analysis of pro-anorexia blogs to better understand the influence of social and cultural pressures | Positive relationship found between social and cultural pressures and engaging in self-harming/destructive behaviours | Negative | QualitativeLow |
a: Part of a three part series related to online interventions. Subsequent two papers while cited in press have publication dates outside of current search
b: Five reports related to the same self-harm forum study (Sharptalk)
c: Lesbian Gay Bisexual and Transgender
d: Two reports based on the same set of eating disorder blogs