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To cite: Alexander ED, Chung V-­
H-A­ , Yacovelli A, et al. Social
media and postsecondary
student adoption of mental
health labels: protocol for a
scoping review. BMJ Open
2024;14:e078193. doi:10.1136/
bmjopen-2023-078193
► Prepublication history
and additional supplemental
material for this paper are
available online. To view these
files, please visit the journal
online (https://doi.org/10.1136/​
bmjopen-2023-078193).
Received 26 July 2023
Accepted 15 January 2024
© Author(s) (or their
employer(s)) 2024. Re-­use
permitted under CC BY-­NC. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
1
CIET-­PRAM, Department
of Family Medicine, McGill
University, Montreal, Quebec,
Canada
2
GESTS, Escuela de Medicina
y Ciencias de la Salud,
Universidad del Rosario, Bogota,
Cundinamarca, Colombia
3
Centro de Investigación de
Enfermedades Tropicales (CIET),
Universidad Autonoma de
Guerrero, Acapulco, Guerrero,
Mexico
Correspondence to
Ethan Dylan Alexander;
​ethan.​alexander@m
​ ail.​mcgill.c​ a
Social media and postsecondary student
adoption of mental health labels:
protocol for a scoping review
Ethan Dylan Alexander ‍ ‍,1 Van-­Han-­Alex Chung,1 Alexandra Yacovelli,1
Ivan Sarmiento ‍ ‍,1,2 Neil Andersson1,3
ABSTRACT
Introduction Many postsecondary students use social
media at an age when mental health issues often arise
for the first time. On social media, students describe their
mental states or social interactions using psychiatric
language. This is a process of mental health labelling
as opposed to receiving a formal diagnosis from a
psychiatrist. Despite substantial literature on psychiatric
labelling effects such as stigma, little research has
addressed the mechanisms and effects of labelling
through social media. Our objective is to summarise the
existing evidence to address this gap.
Methods and analysis This review includes articles
in English published since 1995 on how postsecondary
students interact with mental health labels in their use
of social media. We will consider empirical studies and
theses. The search strategy includes SCOPUS, PubMed,
OVID MEDLINE (to access APA PsycINFO), Web of Science
and ProQuest Global Dissertations and Theses. This
scoping review follows the Preferred Reporting Items for
Systematic Reviews and Meta-­Analyses extensions for
protocols and Scoping Reviews guidelines. The artificial
intelligence application, Connected Papers, will assist
in identifying additional references. The outcomes of
interest are labelling by self or others and changes in
self-­concept and presentation associated with these
labels. Two researchers will independently identify the
included studies and extract data, solving disagreements
with a third opinion. We will produce tables and narrative
descriptions of the operationalisation and measurement
methods of labelling and social media use, reported effects
and uses of labelling, and explanatory mechanisms for the
adoption of labels.
Ethics and dissemination This literature review does not
require ethics approval. The researchers will present their
findings for publication in an open-­access peer-­reviewed
journal and at student/scientific conferences. Potential
knowledge users include university students, social media
users, researchers, mental health professionals and on-­
campus mental health services.
INTRODUCTION
The rising prevalence of mental health
problems among postsecondary students
is a global concern.1 Many postsecondary
students use social media at an age when
mental health issues often arise for the first
Alexander ED, et al. BMJ Open 2024;14:e078193. doi:10.1136/bmjopen-2023-078193
Protocol
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒ Mental health labelling is not well defined and re-
quires a broad search strategy including identity,
stigma and self-­disclosures.
⇒ Including theses allows for insights and viewpoints
from postsecondary student authors.
⇒ Limited to English papers, theses and dissertations.
⇒ The heterogeneity of the literature limits inferences
about the effect of labelling on health outcomes,
although it does allow general theories on mecha-
nisms of action.
time.2 Social media can be a mental health
resource for students because it is easy to
use, free and makes much information avail-
able, although without clear indications of
scientific validity.3 Roughly one-­third of US
postsecondary students reported searching
for mental health information online at least
once.3
We do not yet fully understand the impact
of unlimited access to mental health infor-
mation.4 Existing research has highlighted
activities, motivations and communication
partners as three major dimensions that
affect well-­being. Despite this, few researchers
have considered labelling processes on social
media.5 While some users can find health
information that facilitates seeking treat-
ment or social support, others can experi-
ence cyberchondria, using the internet to
create cycles of increasing concern about
health6 or join social spaces that see psychi-
atric illness such as anorexia as a way of life.7 8
There are strong concerns about the overin-
terpretation of mental illness as a result of
heightened cultural awareness and fears that
illness is being encouraged.9 Lindholm and
Wickström explored how young people use
psychiatric labels such as anxiety and depres-
sion when discussing their mental well-­being
offline. In their everyday use of these labels,
youth devalue and separate pathological
connotations from new cultural ones. This
1
Open access
has led to the application of these labels to deal with the
ups and downs of life.8
Algorithms are crucial in determining what users see
on social media by combining their interests and engage-
ment patterns.10 The mood of users can affect their
engagement behaviour. When feeling down, individuals
may spend more time viewing sad content, which can
skew recommendations from the algorithm to suggest
additional sad content.11 The affective nature of the
information presented can prime users to deeply identify
with information presented as diagnostic criteria.11 When
Instagram censored posts containing hashtags related to
eating disorders in response to public concerns about
increasing eating disorder (ED) prevalence, users adapted
the censored words to preserve their community.12
For this review, we will define mental health labelling
as the categorisation process used to discriminate and
identify mental disorders or mental health problems.13
Labelling can be a formal diagnostic process, an informal
process carried out by peers, or a self-­ driven process.
Labelling by others can occur due to self-­presentation/
disclosure, and self-­labelling is linked to self-­concept and
stigma.14 Mental health labels can be tools for navigating
university life by allowing individuals to gain sympathy
from peers and professors when asking for grace.15 Early
labelling theory pioneered by Thomas Scheff argued
that mental illnesses were minor forms of social devi-
ance. A society labelling a deviant person as mentally ill
alters how they are treated and pressures the individual
to behave in accordance with the label, thus creating a
self-­perpetuating cycle.16 Link et al further developed
labelling theory with the argument that labelled individ-
uals have agency in responding to societal conceptions of
mental illness.17 They can recuse themselves from society
or try educating the public to shift public opinion.17
The labelling process is also shaped by looping effects, a
term coined by Ian Hacking, who explained how people’s
behaviour and cognition change in response to psycho-
logical classification and how classifications change in
response to the behaviours of groups.18 When an indi-
vidual or group feels at odds with their label, classification
incongruence leads to destabilising looping effects.19 For
example, some patients hid their auditory hallucinations
from doctors to avoid being labelled as having schizo-
phrenia, which led to auditory hallucinations receiving
less attention in future diagnostic guidelines.19 Conversely,
if individuals perceive congruence with a diagnosis, they
will likely report relief in learning that they are not alone
and that their experiences have shared biopsychological
origins.20 Individuals satisfied with a label can engage in
biosolidarity by raising awareness and sharing support.7 20
The rationale for this review
We could not find any published systematic reviews
discussing looping effects and labelling theory as they
affect social media users. Much of the existing research
is concerned with measuring those with formal diagnoses
and how to encourage treatment seeking through social
2 Alexander ED, et al. BMJ Open 2024;14:e078193. doi:10.1136/bmjopen-2023-078193
BMJ Open: first published as 10.1136/bmjopen-2023-078193 on 13 February 2024. Downloaded from http://bmjopen.bmj.com/ on February 15, 2024 by guest. Protected by copyright.
media. Existing literature reviews have covered the ability
of artificial intelligence (AI) to detect depression and
label users,21 ways that health professionals can deliver
interventions through TikTok using dialogic loops22 and
avoiding ‘judgement or labelling’ when seeking mental
health help online.23 This research will contribute to
existing knowledge by synthesising current information
about the labelling processes on social media and filling
the gap between formal and informal labelling processes
as well as how postsecondary students engage with these
processes on social media.
METHODS AND ANALYSIS
Design and objectives
This scoping review follows the Preferred Reporting Items
for Systematic Reviews and Meta-­ Analyses (PRISMA)
extensions for protocols24 and Scoping Reviews guide-
lines.25 It also follows the considerations proposed by
Peters et al,26 Levac et al27 and Arksey et al.28 Our objec-
tives are to map existing evidence linking social media to
the adoption and use of mental health labels. This differs
from the current research landscape because it focuses
on informal labelling as a potential mediator of psycho-
logical well-­being.
Research question
The overall research question is.
► To what extent do social media platforms influence
postsecondary students’ adoption of mental health
labels?
Specific questions include
► How do researchers operationalise mental health
labelling?
► How do researchers measure social media exposure
on social media platforms?
► How does university students, researchers and mental
health professionals use mental health labels?
► What are the reported effects of using mental health
labels?
► What mechanisms have been reported to lead to the
acquisition of mental health labels from social media?
Eligibility criteria
References included in the review must be published in
English between 1995 and 2023, as this coincides with
the rise of the internet and the proliferation of social
media. We will include empirical studies and theses.
Included studies should directly report on mental health
labelling in the context of social media. The studies
should include postsecondary students, defined as those
attending colleges, universities or institutes with the goal
of attaining an academic degree. Postsecondary educa-
tion occurs after mandatory schooling has finished.
We will exclude studies that do not present disaggre-
gated data on students enrolled in postsecondary insti-
tutions at the time of data collection. Reviewers will also
exclude systematic reviews, studies on academic or career

Table 1 Terms used to develop the search strategy
Topic (joined by Population:
AND operator) postsecondary students
Keywords (Joined (Universit*
by OR operator) Colleg*
Post-­secondary) and
(Studen*)
outcomes of social media users, and online learning and
studies on online mental health education or informa-
tion technology literacy.
Search strategy
The review will cover five databases: SCOPUS, PubMed,
OVID MEDLINE (APA PsycINFO 1967–2023), Web of
Science and ProQuest Global Dissertations and Theses.
These databases were chosen for breadth during consul-
tation with a librarian at McGill University. In addition,
Connected Papers, an AI tool that creates visual maps of
related documents, will be used to supplement the results
with closely related papers not included in the search.
Connected Papers can show shared references across
papers and may point out important links not found in the
initial search. We will look for search terms in the titles,
abstracts and key terms. We have chosen to use truncation
and phrase searching methods to refine our results. Our
use of AI will allow us to cover papers that may not have
been included in the initial searches. Table 1 presents
the search terms used to develop the search strategy, and
online supplemental file 1 contains the search strategies.
Study selection
Reviewers will use Covidence to manage records and
data throughout the review. Two reviews will complete
a primary selection independently, as recommended
by Levac et al27 screening titles and abstracts against the
eligibility criteria. The reviewers will reassess the included
references on the basis of full-­text reading and document
reasons for exclusion. If conflicts arise, a third reviewer
will make the decision. The selection process will be
reported using the PRISMA flow diagram.
Data collection process
Data extracted from the studies will be collected into a
chart created collaboratively by the team, including both
descriptive numerical summary and a thematic analysis as
recommended by Arksey et al28:
Citation information: title, authorship, study location
and study dates (from/to).
Study details: study population, level of postsecondary
students, sample size, study type and a short summary of
findings.
In addition, we will record operational definitions
of mental health labels, the specific social media plat-
forms studied, and summarise the proposed labelling
Alexander ED, et al. BMJ Open 2024;14:e078193. doi:10.1136/bmjopen-2023-078193
Open access
BMJ Open: first published as 10.1136/bmjopen-2023-078193 on 13 February 2024. Downloaded from http://bmjopen.bmj.com/ on February 15, 2024 by guest. Protected by copyright.
Intervention: social Outcome: mental
media Outcome: labelling health
“Social media” Labe* “Mental Health”
“Social networking Sit*” Stigma “Mental Illness”
Online “Self-­disclosure” “Mental Disord*”
“Self-­presentation” welln*
Identif*
Self-­diagnosis)
mechanisms. To understand mechanisms, our study will
borrow from realist configurations.29 Mechanisms are
accounts of the processes that lead to an outcome.30
They describe how the use of social media influences the
reasoning and behaviour of users to change their rela-
tionship with the studied outcomes, adoption and usage
of mental health labels. We will identify the statements in
the included reports that suggest theories of causal path-
ways and will compile and summarise them to present
an overall synthesis.30 Each mechanism will have a quote
from the report to support its inclusion in the list. The list
will also clarify the specific outcome to which the mecha-
nism might be related and the contextual elements that
might affect these relationships according to the informa-
tion reported in the paper.
Synthesis
We will collect data on the number of studies published
and the methodology used to show the amount of existing
research in the field and possible gaps in the research. In
addition, a narrative synthesis will be used to map studies
and to discuss the research questions. The presentation
of results will consider the subgroups of postsecondary
students reflected in the students.
Quality assessment
We will use the Mixed Methods Appraisal Tool (MMAT
2018)31 to report the overall quality of the included
studies and their implications for the interpretation of
our results. Quality will not determine inclusion.26 This is
because the objective of this review is to map all available
evidence rather than to provide an empirical or clinically
meaningful result.
Patient and public involvement
Three university students are leading this review. There
was no other patient or public involvement in the
design, conduct and synthesis of this review. We aim
to discuss and contrast our findings with user experi-
ences following a protocol based on fuzzy cognitive
mapping32 (ethical approval by McGill University IRB,
A00-­B27-­23B/23-­05-­034).
Ethics and dissemination
This literature review uses published secondary data and
does not require ethical revision. We aim to disseminate
the results to stakeholders through McGill University
3
Open access
student-­run magazines and student conferences. We will
disseminate the results on social media, particularly on
Instagram.
DISCUSSION
Potential findings
The scoping review will summarise the mechanisms
through which postsecondary social media users adopt
and use mental health labels. We hope to highlight
the crucial role that social media plays in the labelling
process, as individuals identify with mental health labels
through online interactions and discussions.11
Links to related work
Using the definition of mental health labelling as the
categorisation process to discriminate and identify
mental disorders or problems as a starting point, this
scoping review establishes connections with existing
research on labelling theory.4 7 8 This fits in with larger
debates about self-­ presentation, disclosure and self-­
labelling in the construction of identity and stigma as
part of mental health interpretations. The review delves
into the evolution of labelling theory, using early works
by Thomas Scheff on mental illnesses as forms of social
deviance.16 17 The scoping review also incorporates Hack-
ing’s notion of looping effects,18 19 shedding light on the
nuanced interplay between labels and individual expe-
riences. The review’s identification of social media as a
space for individuals to identify with mental health labels
is consistent with studies exploring online communities
and their influence on identity formation.10 33 34 These
links highlight the interconnected nature of informa-
tion dissemination, mental health awareness and identity
development in the digital age.
Potential limitations
The rapidly evolving nature of social media platforms
and online communication may render some findings
outdated or incomplete over time.35 Additionally, the
focus on psychosocial consequences may not capture
the full spectrum of impacts related to mental health
labels, such as the influence on help-­seeking behaviour
or treatment adherence. We are not including papers in
other languages or those without full text, which limits
the scope of the review. Future research should explore
these aspects in more depth and consider the nuances
associated with specific demographics, cultural contexts
and evolving online communication trends.
Implications
Our findings could suggest how mental health profes-
sionals, advocates and policymakers need to adapt their
strategies to the changing landscape of information
consumption. Our review will help identify gaps in the
research that may prevent unintended psychosocial conse-
quences of social media use for postsecondary students.
4 Alexander ED, et al. BMJ Open 2024;14:e078193. doi:10.1136/bmjopen-2023-078193
BMJ Open: first published as 10.1136/bmjopen-2023-078193 on 13 February 2024. Downloaded from http://bmjopen.bmj.com/ on February 15, 2024 by guest. Protected by copyright.
Acknowledgements We would like to acknowledge research assistants Andrés
Rojas-­Cárdenas and Librarian Genevieve Gore, who guided the search strategy.
Contributors EDA conceived the idea for the review and led the development of
the protocol. AY and V-­H-­AC read and revised the protocol and contributed to its
development. NA and IS acted as guarantors for this project and supported the
development of the review from the original idea.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the
design, or conduct, or reporting, or dissemination plans of this research. Refer to
the Methods section for further details.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer-­reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
Ethan Dylan Alexander http://orcid.org/0009-0006-1176-3806
Ivan Sarmiento http://orcid.org/0000-0003-2871-1464
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