Risks to Privacy of Using Social Media: Understanding the Views of Social Media Users with Serious Mental Illness

Abstract

Objective:

Social media may afford new opportunities to enhance mental health services; however, privacy risks have received less attention. We explored privacy risks of using social media for mental health from the perspectives of social media users with serious mental illness.

Methods:

Twitter users who self-identified in their profile as having a serious mental illness participated in an online survey inquiring whether they are: “ever concerned about risks to their privacy when using social media for anything related to their mental illness”. We compared user characteristics between those concerned about risks and those who were not, and analyzed participants’ open-ended responses about privacy risks thematically.

Results:

Among 90 respondents who self-identified as having schizophrenia spectrum disorders (40%), bipolar disorder (37%), or major depressive disorder (23%), over one third (36%) expressed concerns about privacy risks with using social media. Risks were more frequently reported among respondents with a college degree compared to those without a college degree (45% vs. 22%; χ²=8.65; p=0.010), and among respondents who were currently working compared and/or in school to those who were not currently working (47% vs. 26%; χ²=4.31; p=0.038). Thematic analysis of participants’ open-ended responses yielded four categories of risk: threats to employment; fear of stigma and being judged; impact on personal relationships; and facing hostility or being hurt.

Conclusions:

These findings offer preliminary insights about the types of privacy risks that individuals with serious mental illness are concerned about when using social media for their mental health, and can inform the safety of future social media interventions.

Introduction

The impact of serious mental illness is significant for afflicted individuals, their families, and society, as these disorders contribute to elevated risk of poverty, homelessness, substance use, early mortality, and suicide (1, 2). Many individuals living with serious mental illness, including schizophrenia spectrum disorders, bipolar disorder, or major depressive disorder, do not receive adequate treatment, and many available treatments are of poor quality or lack robust evidence (3). As digital technologies become more affordable and offer increasingly sophisticated features, there may be novel opportunities to bridge gaps in mental health services, and deliver better quality and more effective treatments to persons with serious mental illness (4).

Social media, in particular, has gained considerable attention as a potentially viable digital platform for reaching individuals living with serious mental illness (5). Recent studies have demonstrated that these individuals use popular platforms like Facebook, Instagram, and Twitter at comparable rates as the general population (6, 7). Exploratory work suggests that people living with serious mental illness use social media for connecting with others with similar mental health conditions, seeking information, or sharing personal experiences of living with mental illness (8–10). Therefore, growing recognition that online social networks are used daily by many individuals living with serious mental illness has sparked excitement surrounding the promise of leveraging these platforms for improving services. For example, pilot studies have demonstrated the acceptability of using Facebook to promote engagement and peer-to-peer support as part of lifestyle interventions delivered through community mental health settings (11, 12). Additionally, a recent review found that peer-to-peer interactions, which is a common feature of social media, can potentially enhance engagement and retention in digital interventions among persons with psychosis (13). Drawing from these early efforts, social media may yield new ways to enhance or augment various mental health services, and as expressed by individuals with mental illness, this could include delivery of interventions to promote wellness, support coping with mental health symptoms, or navigating the health care system (14).

The future success of social media interventions will need to ensure that the benefits of these programs outweigh potential harms, and that there are adequate protections to minimize risk. Commonly discussed risks of using social media for mental health interventions typically relate to participant privacy, informed consent, confidentiality, worsening of symptoms, and unintended consequences of disclosing personal information online (15, 16). To date, however, little is known about risks of using social media for mental health from the perspectives of individuals living with serious mental illness. In this study, our objective was to determine whether social media users who self-disclose as having a serious mental illness express risks to their privacy when using social media related to their mental health. We then examined whether respondents who express privacy risks differ on demographic and clinical characteristics from those who do not express privacy risks. Lastly, we asked individuals to explain the reasons why they may have reported experiencing risks to their privacy. By obtaining a better understanding of privacy risks from the perspectives of target users, it will be critical for informing the design of social media interventions that can safely support the needs of individuals living with serious mental illness.

Methods

Study Design

From May to December 2016, we recruited individuals on Twitter who self-identified as having a serious mental illness to complete a survey. Twitter is a popular microblogging platform with over 330 million active users (17, 18), where users post short messages called “tweets” containing up to 140 characters (in 2018 this increased to 280 characters). We searched Twitter for user accounts using the following terms: “schizophrenia”; “schizoaffective”; “schizotypal”; “psychosis”; “bipolar disorder”; “major depression”; and “depression”. We could only identify Twitter users who self-identified in their profile, or in a tweet or caption as having a serious mental illness, and who had publicly accessible accounts. We used the Twitter platform to contact these individuals directly with a personalized tweet asking if they would be willing to answer a short survey. We then sent a follow up tweet containing the link for the online survey to any Twitter users who responded to the initial tweet and indicated that they would be willing to answer the survey. As this was an exploratory study, our target was to achieve 100 survey respondents who self-identified as having a serious mental illness. We did not compensate participants for completing the surveys. We received ethical approval for this study from the Committee for the Protection of Human Subjects at Dartmouth College.

Data Collection

We created the survey in English using Qualtrics online survey software. To minimize potential risks for survey respondents, we kept the survey anonymous by not collecting any personally identifying information. We collected: demographic information including age, gender, ethnicity, education, living situation, and employment status (including full-time employment, part-time employment, or currently in school); clinical information including mental illness diagnosis, number of hospitalizations due to mental illness, and severity of mental health symptoms; and social media use including frequency of use, types of social media platforms used (see footnote in Table 1 for details on each platform), and reasons for using social media for anything related to mental health. Lastly, we asked participants about their experiences with risks using social media for their mental health with the following question: “Are you ever concerned about risks to your privacy when you use social media for anything related to your mental illness?” If participants answered “YES”, it was followed with an open-ended question asking participants to describe their experiences of risks to their privacy (“If YES, please describe’).

Table 1.

Demographic and clinical characteristics of respondents with serious mental illness who report and do not report concerns about risks to privacy with using social media for mental health

Characteristic	Number of respondents (N=90)a		Are you ever concerned about risks to your privacy when you use social media for anything related to your mental illness?				Pb
			Yes (N=32)		No (N=58)
Demographic characteristics	N	%	N	%	N	%
Gender							0.080
Male	27	31	6	19	21	38
Female	60	69	25	81	35	63
LGBTQ	5	6	0	0	5	9	0.156
Age Group							0.270
≤30 years	26	29	7	22	19	33
31–40 years	26	29	9	28	17	29
41–50 years	21	23	12	38	9	16
>50 years	17	19	4	13	13	22
Race/ethnicity							0.708
Asian	4	3	1	3	2	4
Black/African American	6	7	3	9	3	5
Caucasian/non-Hispanic white	74	82	26	81	48	83
Hispanic or Latino	3	3	1	3	2	4
Native	1	1	1	3	0	0
Education							0.010*
Less than college degree	41	46	9	28	32	55
College degree	47	52	21	66	26	45
Currently in school	2	2	2	6	0	0
Employment							0.038*
Currently workingc	43	48	20	63	23	40
Not currently workingd	47	52	12	38	35	60
Living situation							0.733
Live alone	25	28	7	22	18	31
Live with family	34	38	12	38	22	38
Live with my partner (e.g., spouse, significant other)	24	27	11	34	13	22
Live with roommates	3	3	1	3	2	4
Supported housing	2	2	0	0	2	4
Clinical characteristics
Primary mental illness diagnosis							0.727
Schizophrenia spectrum disorder	36	40	12	38	24	41
Bipolar disorder	33	37	11	34	22	38
Major depressive disorder	21	23	9	28	12	21
Number of times hospitalized for mental illness							0.280
Several times	54	60	17	53	37	64
One time	14	16	4	13	10	17
Never	21	23	10	31	11	19
How often mental health symptoms interfere with daily activities (such as work, school, recreation, or other activities)							0.360
Not at all	2	2	0	0	2	4
Minimal (can be easily ignored without effort)	3	3	0	0	3	5
Mild (can be ignored, but does not affect my daily activities that much)	11	12	5	16	6	10
Moderate (cannot be ignored and occasionally affects my daily activities)	42	47	18	56	24	41
Severe (cannot be ignored and frequently limits my daily activities)	20	22	5	16	15	26
Very severe (cannot be ignored and always affects my daily activities)	11	12	3	9	8	14

^aThere were a total of 91 survey respondents who self-reported having a primary diagnosis of serious mental illness, defined as either schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder; one respondent did not answer the question about risks of using social media and was excluded from this table.

^bWe used descriptive statistics, including chi-square tests and Fisher’s exact tests (when the expected value of a cell was <5), to explore differences in demographic and clinical characteristics between respondents who expressed risk and those who did not.

^cCurrently working was defined as: full-time employment, part-time employment, or currently in school.

^dNot working was defined as: unemployed, on disability, or volunteered, retired, or a caregiver.

^*Denotes statistical significance defined as P <0.05.

Data Analysis

We tabulated survey responses to generate summary statistics. We used descriptive statistics, including chi-square tests and Fisher’s exact tests (when the expected value of a cell was <5), to explore differences in demographic and clinical characteristics, and patterns of social media use between respondents who expressed risk and those who did not. We used Stata 14.0 for all statistical analyses. For the thematic analysis of open-ended responses, we applied a conventional content analysis approach involving open coding of the responses (19). We assigned codes to the responses as the data was studied, and re-reviewed the data to identify new codes (20). We grouped similar codes for the participant responses together into categories that were allowed to flow from the data (21). We avoided using pre-conceived codes or categories because this study was aimed at exploring privacy risks from the perspectives of social media users with serious mental illness, and there has been limited research on this topic to date. The lead author (Dr. X) read through the open-ended responses several times, and assigned codes based on key topics that were mentioned. Several codes were grouped together into broader categories, though many of these codes ended up being the name of the actual category. The second author (Dr. Y) reviewed the codes that were assigned to participant responses, and the list of overarching categories. Both authors discussed the final categories to reach consensus. The thematic analysis of participants’ open-ended responses was used to complement the quantitative survey responses.

Results

Study Sample

We contacted the first 207 individuals we found from searching the Twitter platform who self–identified as having a serious mental illness. In total, 94 agreed to complete the online survey. Ninety respondents who self-identified as having schizophrenia spectrum disorders (40%), bipolar disorder (37%), or major depressive disorder (23%) completed surveys. Respondents were primarily from the United States (66%), Canada (13%), or the United Kingdom (13%), though we also had one respondent each from Australia, Denmark, Malaysia, the Netherlands, Grenada, and Singapore. The sample reported being predominantly non-Hispanic white (82%), over two thirds (69%) female, and over half age 40 and younger (58%). Half of respondents had a college degree (52%), and nearly half were currently working (defined as: full-time employment, part-time employment, or currently in school; 48%). Over half of respondents reported being hospitalized several times for their mental illness (60%), and most (81%) indicated that they experience moderate to very severe mental health symptoms that interfere with their daily activities, such as work, school, recreation, or other activities. Participants were frequent users of social media, with 93% reporting using social media daily. Many participants also reported using social media to connect with others who have a mental illness (72%), share personal experiences about living with mental illness (42%), and learn about strategies for coping with mental illness (67%).

Privacy Risks

Among the 90 respondents, 32 (36%) indicated “Yes’” to the question asking whether they are ever concerned about risks to privacy when using social media for anything related to their mental illness. In Table 1, we compare demographic and clinical characteristics between participants who expressed concerns about risks to privacy and those who did not. A greater proportion of female respondents (42%) compared to male respondents (22%) expressed concerns about risks to privacy, though this difference was not statistically significant. A significantly greater proportion of respondents with a college degree (45%) were concerned about risks to privacy compared to those without a college degree (22%; χ²=8.65; df=2; p=0.010). For employment status, a greater proportion of respondents who were currently working or in school (47%) compared to those who were not currently working (26%) expressed concerns about risks to privacy (χ²=4.31; df=1; p=0.038). In Table 2, we compare respondents’ frequency and type of social media use by privacy risk reporting. Among respondents who use WhatsApp, a greater proportion expressed concerns about risks to privacy compared to those who did not (58% vs. 42%; χ²=7.41; df=1; p=0.006).

Table 2.

Frequency and type of social media use among respondents with serious mental illness who report and do not report concerns about risks to privacy with using social media for mental health

Social Media Use	Number of respondents (N=90)a		Are you ever concerned about risks to your privacy when you use social media for anything related to your mental illness?				Pb
			Yes (N=32)		No (N=58)
	N	%	N	%	N	%
Frequency of social media use							0.052
Daily	84	93	28	88	56	97
At least once each week	5	6	4	13	1	2
Less than once each week	1	1	0	0	1	2
Types of social mediac
Twitter	90	100	28	88	51	88	0.952
Facebook	82	91	28	88	54	93	0.371
Instagram	42	47	15	47	27	47	0.977
YouTube	61	68	21	66	40	69	0.745
Snapchat	20	22	10	31	10	17	0.126
WhatsApp	24	27	14	44	10	17	0.006*
Pinterest	29	32	11	34	18	31	0.745
How social media is usually accessed
Own Phone	76	84	27	84	49	85	0.989
Own Computer	58	64	18	56	40	69	0.228
Own Tablet	35	39	13	41	22	38	0.802
Someone else’s device	5	6	1	3	4	7	0.652
What are the main reasons you use social media?
Connect with others who also have mental illness	65	72	24	75	41	71	0.662
Learn about mental illness from others	38	42	13	41	25	43	0.820
Share personal experiences about living with mental illness	60	67	22	69	38	66	0.755
Learn about strategies for coping with mental illness	45	50	17	53	28	48	0.660
How often do you use social media to search for information about your mental illness?							0.474
Daily	24	27	7	22	17	29
At least once each week	32	36	10	31	22	38
At least once each month	14	16	5	16	9	16
Less than once each month	20	22	10	31	10	17
How often do you use social media to connect with other people who also have a mental illness?							0.765
Daily	44	49	14	44	30	52
At least once each week	25	28	9	28	16	28
At least once each month	7	8	2	6	5	9
Less than once each month	12	13	6	19	6	10

^aThere were a total of 91 survey respondents who self-reported having a primary diagnosis of serious mental illness, defined as either schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder; one respondent did not answer the question about risks of using social media and was excluded from this table.

^bWe used descriptive statistics, including chi-square tests and Fisher’s exact tests (when the expected value of a cell was <5), to explore differences in patterns of social media use between respondents who expressed risk and those who did not.

^cThe survey asked about participants’ use of several popular social media platforms, each of which offers unique features: Twitter, microblogging platform where users post short messages called “tweets”; Facebook, web application where users can create profiles, upload photos, text, or video content, send messages, and connect with other users; Instagram, mobile photo-sharing application where users can upload, view, or like photos or short videos; YouTube, online video sharing platform where users can watch videos posted by others or upload their own videos; Snapchat, mobile application for sending or receiving photos or videos that can only be viewed once, and that disappear from the recipient’s device; WhatsApp, mobile messenger application for sending messages, images, audio, or video; and Pinterest, web application where users can upload, save, and manage images or other media content called ‘pins’.

^*Denotes statistical significance defined as P ≤0.05.

Qualitative Findings

Among participants who expressed concerns about privacy, 28 (88%) completed the open-ended question that followed. After coding these 28 responses, we identified four overarching categories reflecting participants’ key concerns about risks to privacy with using social media for mental health. Table 3 provides a summary of these categories and sample responses from participants. Below, we describe these categories in greater detail:

1. Threats to employment. This was a prominent topic to emerge from participants’ responses, with 11 out of 28 (39%) respondents emphasizing their concerns that using social media for their mental health could negatively impact their current employment, or seriously affect future prospects for obtaining a job or being promoted.

2. Fear of stigma and being judged. Many participants’ described fears of others finding out and judging them, and cited lack of tolerance or understanding of mental illness as concerns.

3. Impact on _personal relationships. Several participants mentioned concerns that either a spouse or someone that they know may find out about their use of social media for their mental health, such as disclosing their mental health challenges online. Others indicated that they were concerned that using social media in this way could affect their dating life.

4. Facing hostility or being hurt. Some participants expressed concerns about being harassed by spam (e.g., irrelevant or inappropriate messages), bots (e.g., automated responses or conversations online), or trolls (e.g., offensive or provocative online posts). One participant mentioned facing “haters or hackers” on social media, while others mentioned potentially being hurt if others find information about them online.

Table 3.

Thematic categories for participants’ open-ended responses describing their reasons for being concerned about risks to privacy with using social media for their mental health

Major categories	Codes for each category	Sample responses from participants
Threats to employment	Employer finds out Not being hired Affect career and promotion	“In case my employer found out.” [Female participant, age 41–50 years, with schizophrenia spectrum disorder] “I’m afraid if I ever apply for a job, they’ll look at my posts (some I’m not proud of, because of my mental illness), and not hire me/fire me.” [Male participant, age ≤30 years, with schizophrenia spectrum disorder] “I sometimes worry about it what I post could prevent me from getting a job in the future.” [Female participant, age 31–40 years, with major depressive disorder] “When I was employed (disabled now) I would NEVER post about my mental illness for fear that my (or any potential) employer would find out and use it as a base for discriminating against me in hiring, eval, and promotions.” [Female participant, age 41–50 years, with major depressive disorder] “That is why I tweet anonymously otherwise diagnosis could affect my career standing and promotion.” [Female participate, age 41–50 years, with bipolar disorder] “I hate feeling like future prospective employers might find something about my illness on social media and decide against giving me an interview or hiring me.” [Female participant, age 41–50 years, with bipolar disorder]
Fear of stigma and being judged	Stigma Fear of being judged Others finding out	“Yes, sometimes I have been concerned about sharing online & writing a memoir because the stigma, discrimination & lack of compassion is still very much pervasive in society, in schools & in workplaces…. stigma is a massive problem.” [Female participant, age 41–50, with major depressive disorder] “I am careful I don’t give too much detail. I’ll share diagnosis and some about symptoms, but I don’t get too negative or into some details in my life I feel are private.” [Male participant, age 31–40, with bipolar disorder] “Many people are not understanding or tolerant of mental illness…” [Female participant, age 41–50, with schizophrenia spectrum disorder] “I worry people will find out some things about me and judge or get upset.” [Female participant, age >50 years, with schizophrenia spectrum disorder] “There’s always risk involved when posting personal info on social media. You open yourself up to the opinions of others.” [Female participant, age ≤30 years, with major depressive disorder].
Impact on personal relationships	Spouse could find out Personal relationships Impact on dating	“I’m concerned that people I know will find my account.” [Female participant, age <30 years, with major depressive disorder] “I worry that my work and spouse will find personal/anonymous things that I write.” [Male participant, age 41–50 years, with bipolar disorder] “… So when it comes to dating and work I am often terrified of the possible outcome.” [Female participant, age 31–40 years, with bipolar disorder] “… despite the very real reality that my openness will cause some men not to want to date a “crazy girl” or an employer to question my capabilities, I continue to publicly share more and more over time.” [Female participant, age 41–50, with major depressive disorder]
Facing hostility or being hurt	Bots and spam Haters and hackers Being hurt	“Hackers and haters.” [Female participant, age 31–40 years, with schizophrenia spectrum disorder] “I worry that my info will be hacked and released to the public.” [Male participant, age 41–50 years, with schizophrenia spectrum disorder] “Get information about me and find me and hurt me.” [Female participant, age >50 years, with major depressive disorder] “…I know it could be used against me one day. That’s cause for reservation occasionally.” [Male participant, age 31–40 years, with bipolar disorder]

Discussion

We found that about one third of individuals who self-identified as having a serious mental illness online reported concerns about risks to their privacy with using social media for their mental health. Importantly, participants who were concerned about risks to their privacy were more likely to have a college degree. This is consistent with literature showing that people who have a higher level of education also have greater health literacy and digital literacy (22). Specifically, digital literacy is reflective of greater user knowledge, and is associated with increased awareness and understanding of privacy-related online behaviors (23). While our sample consisted of high users of social media with overall high education levels, we cannot assume that they are familiar with available options to protect their privacy online. Even though we did not ask about participants’ familiarity with or use of privacy settings on their social media accounts, research from the general population suggests that nearly half of social media users report some difficulty managing their privacy settings (24). The high education levels of our sample is consistent with research from the general population showing that a greater proportion of social media users have college degrees compared to high school or less education (25). This also shows that we were unable to reach people with serious mental illness with lower education levels, and therefore we may have a limited understanding of their perceptions of risk.

Second, participants who were concerned about risks to their privacy were also more likely to be currently employed, which aligns with the finding related to education as educational attainment is correlated with employment in persons with serious mental illness (26). Furthermore, the impact of privacy risks on employment status emerged as a prominent theme from participants’ open-ended responses. Many participants expressed concerns about risks with using social media as it relates to their current job tenure, prospects for promotion, and seeking future employment opportunities. This finding is noteworthy given the challenges people with serious mental illness face in obtaining and keeping steady employment (27), as well as the benefits of gainful employment including improved functioning, reduced utilization of outpatient mental health services, increased self-esteem, and successful recovery (28–31). Therefore, the development and delivery of interventions using social media will need to balance potential benefits with the risks that disclosing information online could impact employment prospects. This finding could also inform the WorkingWell smartphone application for supporting individuals with serious mental illness in the workplace (32), by illuminating the importance of including additional instruction with safety tips about how to use social media while avoiding sharing information online that could negatively impact employment.

Participants in this study were highly active on social media, and they disclosed their mental illness diagnosis publicly on Twitter. This could help explain why about two thirds of participants reported not having any concerns about privacy when using social media for their mental health. It is also plausible that many of participants have embraced online peer-to-peer support as they reported connecting with others who have a mental illness, sharing personal experiences about living with mental illness, and learning about strategies for coping with mental illness as reasons for using social media. Prior research has explored potential benefits of interacting online with others living with similar health conditions, including feeling empowered, learning new skills, and feeling less alone (5, 8, 33, 34). While a review of online social networking among people with psychosis found little evidence of risks (35), prior studies have described risks of self-disclosing stigmatizing health conditions online for various patient groups (36).

Among participants who reported concerns about risks to their privacy, we identified four broad categories of risks. As described above, risks pertaining to employment are especially relevant for people with serious mental illness. For risks related to fear of stigma and being judged, or facing hostility or being hurt, these are consistent with prior literature indicating that social media use could have unintended consequences of subjecting individuals to targeted stigma or cyber-bullying (16). It is noteworthy that participants’ mentioned concerns about how their social media use might impact their personal relationships, as this potentially parallels existing research showing that people with serious mental illness are acutely aware of how their diagnosis impacts their relationships with others in offline contexts (37). Many individuals with serious mental illness experience difficulty forming and maintaining social relationships (38), and they can go to great lengths to manage how they interact with others in public due to feelings of shame and fear that others might find out about their diagnosis (39). A similar scenario could occur on social media platforms, where individuals with serious mental illness recognize the need to carefully manage their online interactions given concerns that others may find out about their diagnosis thereby having a detrimental impact on personal relationships.

Several limitations warrant consideration. First, we recognize that our findings should be interpreted cautiously given the exploratory nature of this study, and small sample of social media users who had disclosed personal information about their mental illness online. Therefore, participants’ responses cannot generalize broadly to people living with serious mental illness or to those who do not openly disclose their mental illness diagnosis online. Second, there were limits to generalizability because a large proportion of our sample had college degrees and were currently employed, and there was limited racial and ethnic diversity. Recent research shows that lower income groups, as well as racial and ethnic minorities, use social media at comparable rates as the overall population (40). This highlights the need to expand on our findings to determine how social media could support the delivery of interventions to hard-to-reach and underserved individuals with serious mental illness who are often underrepresented in traditional mental health service delivery settings. Lastly, we relied on self-reported diagnoses and were unable to confirm participants’ responses using objective clinical data. Because a diagnosis of serious mental illness is associated with stigma, and because we did not compensate participants, it seems unlikely that participants would have been dishonest in their self-disclosure of having a diagnosis of serious mental illness.

Conclusions

Together, our findings demonstrate why it will be essential to involve social media users with serious mental illness throughout the development and delivery of social media interventions given that their major concerns about risks relate directly to several key aspects of their daily lives. Interventions should draw from the perspectives of these individuals to ensure that potential risks related to stigma, harm, or self-disclosure are clearly presented and that content or material is included to educate participants about how to protect themselves. Future research will be necessary to examine additional risks not considered here, such as the potential for worsening mental health symptoms (41), delays in seeking professional help (42), and exposure to misinformation (16). For now, our study contributes novel findings that can immediately guide the ethical and safe use of social media as part of interventions, programs, or services for persons with serious mental illness.

Highlights:

• Social media may afford new opportunities to enhance mental health services for people with serious mental illness; however, risks must be carefully examined.

• This study explored privacy risks of using social media for mental health from the perspectives of social media users with serious mental illness.

• Participants were concerned about threats to employment, fear of stigma and being judged, impact on personal relationships, and facing hostility or being hurt.

• These findings offer insights about privacy risks and can guide the safe use of social media as part of interventions for persons with serious mental illness.