Mental Health: A Quick Overview

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Exhibit 45 CONFIDENTIAL - PROTECTED BY CONFIDENTIALITY AGREEMENT MT-IG-AG-00056857 Mental Health: A Quick Overview Last edited November 13, 2019 ~ 10 minute read TL;DR - Mental Health is both an absence of mental illness and a presence of subjective well-being. It is a state in which an individual is both not mentally ill and flourishing. - On Instagram, mental health issues impact one of our core demographics (teens and younger users), as they generally demonstrate lower well-being. Mental health issues are also a leading driver of well-being complaints related to Instagram. - Social media is often not the cause of problems related to mental health. However, it can and does both attenuate or exacerbate a user's experience with mental health issues. - Therefore solutions to mental health issues should focus on both promoting positive mental health outcomes (enhancing overall well-being) and preventing negative mental health outcomes (prevention and support for the most distressed users). What is mental health? - WHO defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. However it is important to keep in mind that positive functioning and emotions as a constant state may not be appropriate in many situations and negative affect is a part of life. - Mental health therefore includes: Emotional Well-Being, Psychological Well-Being, Social Well-Being Isn't this just subjective well-being? CONFIDENTIAL - PROTECTED BY CONFIDENTIALITY AGREEMENT MT-lG-AG-00056858 Subjective well-being refers to people's evaluation of their own lives, in thoughts and feelings. It includes overall evaluations like life satisfaction as well as the experience of positive feelings (like happiness) and negative feelings (like stress). At the broadest level it also includes people's evaluation of whether their important psychological needs are being met, like having supportive and enriching relationships and feelings of self-worth, mastery, meaning, and autonomy. Mental health and subjective well-being can be seen as originating in different fields; clinical and social psychology respectively. Interestingly, research in subjective well-being unintentionally yielded clusters of mental health symptoms used in the DSM to diagnose depression. For instance, just as depression requires symptoms of anhedonia, mental health consists of symptoms of hedonia such as emotional vitality and positive feelings towards ones life. While social psychology has made great strides in the domain of mental illness (until the 1990's mental illnesses were overlooked as sources of chronic burden), the same cannot be said for the unverified assumption that mental health is the absence of mental illness persisted for some time. In a bid to move away from defining mental health as simply the absence of mental illness, WHO released a 2001 report, outlining their vision of mental health as not just the absence of disorder or struggle with mental health but a state of well-being where individuals are able to cope and flourish - encompassing the definition of mental illness with subjective well-being. Measures of mental illness and mental health (operationalized through measures of subjective well-being) form two distinct continua in US population and there is evidence that only a small proportion of those that are free from mental illness are mentally healthy indicating that the absence of mental illness does not necessarily mean mental health (a subtle assumption when defining mental health). In addition just simply the absence of mental illness - a state defined as "languishing" - has been shown to be as bad as a major depressive episode. Subjective Well-Being The two continua model of mental health This model conceptualizes mental health as suggesting mental health and mental illness, positive (PMH) and negative mental health (NMH), are two correlated but distinct factors. Some aspects of positive mental health are associated with greater levels of life satisfaction, greater positive affect and lesser negative affect, also defined as subjective well-being. On the other hand, negative mental health is most commonly associated with psychopathological symptoms and typically low levels of positive mental health is accompanied by numerous symptoms of depression, anxiety or stress. Studies have indicated that individuals who are languishing are 5 times more likely to suffer from depressive symptoms than those who are flourishing. However it is important to note that flourishing may not guarantee an absence of mental illness, just a lower probability that mental illness occurs. CONFIDENTIAL - PROTECTED BY CONFIDENTIALITY AGREEMENT MT-IG-AG-00056859 [Chart: Prevalence of Complete Mental Health in the U.S. Adult Population in 1995 (Ages 25-74) Compared With an Idealized View of the Distribution of Complete Mental Health. Image from Keyes, 2007] Proposed Definition of Mental Health In our synthesis we propose a simplified version of WHO's definition which clarifies what mental health is and how it relates to subjective well-being and mental illness. Mental Health is both an absence of mental illness and a presence of subjective well-being. It is a state in which an individual is both not mentally ill and flourishing. What does mental health include and how are these factors inter-related? While mental health itself includes a range of issues, for the purposes of this note we will focus specifically on issues that come up in relation to social media use. Past research on mental health and social media use has consistently surfaced a few mental health issues that are particularly relevant to social media generally and Instagram in particular. This list is not exhaustive and should be expanded. - Problematic Use - Depression - Loneliness - Social Comparison - Anxiety - FOMO - Stress - Suicide and Self-Injury - Eating Disorders - Body Image issues - Other mental health disorders (bipolar, schizophrenia etc.) At Facebook, work in mental health has been divided into two work-streams: Understanding subjective well-being and the drivers of subjective well-being (see here) and preventing extreme harm which focusses on suicide, self injury and eating disorders (all grouped under the category of SSI). While these distinctions are helpful for tackling mental health to the extent that it is impacted by social media use, they are more arbitrary than natural. Mental health problems rarely occur in isolation. This means regardless of the CONFIDENTIAL - PROTECTED BY CONFIDENTIALITY AGREEMENT MT-IG-AG-00056860 chronological order these issues occur in, they can co-exist in a person and exacerbate each other. It is also hard to gauge causal relationships as often Problem A can cause/exacerbate Problem B but Problem B can also cause/exacerbate Problem A. [Diagram: Understanding relationships between factors impacting mental health: Expectation vs Reality] In addition, a person's mental health journey is not always linear and the distress they experience may not always progress or regress systematically. Therefore the issues listed above are not discrete issues that can be addressed in a vacuum. Let's take the example of suicide and self-injury. Suicidal distress is not always extreme and can range from curiosity about what others experiencing similar distress are doing to the act of taking one's life following a triggering event. Additionally, a person's journey to suicide or recovery is not always linear. After experiencing moderate levels of distress they might recover or commit suicide, depending on the presence of certain triggers. Additionally, suicidal thoughts can be triggered due to a variety of mental health issues with social media serving as a carrier of these triggers. However, social media may also provide unique opportunities for users to connect with others or seek help when they do not have a support system to lean on more closely by. The lack of linear relationships between some of these mental health dimensions is further complicated by difficulty in determining what the right intervention might be. Taking the example of suicide and self injury for instance: taking down content and hashtags associated with ED/SSI can prevent downward spiral for some but alienate others who are coming to the platform to seek support. So, why should we, as a social media company, care about mental health? What role do we play in our users' mental health and how can we help our users through their journey to better mental health? What does mental health have to do with social media and why should we care? On Instagram in particular, issues related to or impacting mental health have high perceived reach, especially among teens. What is perhaps more surprising is that while overall we either have no impact or make things better, a sizable proportion of users (under a third) think we make issues related to mental health worse. In a survey with over 22000 Instagram users across United States, India, Japan, Indonesia, Brazil and Turkey we found that at least 1 in 2 users had experienced at least one mental health related issue in the last 30 days. We include issues ranging from problematic social media usage to general mental health relevant experiences like social comparison, loneliness, sleep issues, mild depression/sadness, anxiety, FOMO, stress (as a result of work, finance or family), eating issues, body image issues, suicide and self injury. We found that social comparison, SSI, loneliness and problematic social media use especially stand out above other issues when looking at the reach and intensity of issue, expectation of support from Instagram for them and the extent to which we make them worse. CONFIDENTIAL - PROTECTED BY CONFIDENTIALITY AGREEMENT MT-lG-AG-00056861 [Chart: Intensity x proportion IG made worse x Reach (bubble size) of mental health issues among teens on Instagram] There is other evidence across internal and external research that mental health or issues that impact it negatively affect one of our core demographics that also happens to be the most vulnerable - teens. 71% of teens in US use Instagram, the second highest use social network, preceded only by Snapchat. However, IG is perceived as worse for mental health compared to other social media sites like Snap, Twitter, Facebook and Youtube. According to a survey of 1500 young adults, Instagram was ranked as the worst social media app (compared to Snap, Twitter, Facebook and Youtube) for mental health and well being, particularly for its impacts on anxiety and depression. Younger users on Instagram (age 24 and below) also demonstrate lower well-being than older users. More specifically they demonstrate greater depression, loneliness and negative affect. Mental health and SSI is also one of the consistent safety issues that our users report about. Additionally, exposure to non-suicidal self-injury (NSSI) content may increase risks in engaging in these behaviors and consuming NSSI content online can trigger offline NSSI behaviors. Instagram is particularly susceptible to this as it allows for use of anonymous identities and hashtags and is a visual medium. Also parents, regulators and other expert bodies may often struggle to understand how hashtags are being used. Finally mental health issues like anxiety and depression are the leading drivers of well-being complaints related to Instagram. What role does IG (and other social media) play in users mental health? Social media is more of a catalyst than the primary driver of mental health. Social media is often not the cause of problems related to mental health, but we have the power to both positively and negatively influence user's experience with these problems. Users go to social media with the intent to explore, express or connect. While doing so they can have both positive and negative experiences. Many of the negative experiences exacerbate existing mental health issues and mitigating these while promoting positive experiences could lead to better overall well-being for our users. CONFIDENTIAL - PROTECTED BY CONFIDENTIALITY AGREEMENT MT-lG-AG-00056862 [Chart: Positive and Negative experiences in teens as a result of social media use. Positive Experiences: Self-Expression, Exploration, Connection. Negative Experiences: various listed] Social media therefore plays the role of a catalyst more so than being a primary driver of negative mental health (with certain exceptions like problematic use). Hence, we have the ability to drive both positive and negative outcomes related to users' mental health. How can we help our users flourish? Given the role we play, we have the power to both mitigate the bad and hopefully drive the good impact we have on our users' mental health. In addition, we also need to be mindful of the two-continua model of mental health while thinking of interventions and product solutions in this space. Just as not struggling does not mean flourishing, simply removing triggers that cause distress will not help in improving our users' mental health. As such, solutions to mental health issues should therefore focus on both promoting positive mental health outcomes (enhancing overall well-being) and preventing negative mental health outcomes (prevention and support for the most distressed users). Here are some examples of treatments/interventions proposed in past research that both help prevent the negative impact of social media use on mental health and promote the positive impact. CONFIDENTIAL - PROTECTED BY CONFIDENTIALITY AGREEMENT MT-IG-AG-00056863 [Table of treatments/interventions by mental health issue category: Depression, Loneliness, SSI, Social Comparison, etc., listing negative drivers and positive drivers/interventions for each] 24 Comments 2 Comments 4 Shares Like Comment Share "Great note. Thanks for sharing!" Like Reply 2y "This is fantastic - thank you for breaking down a very complex and abstract problem area." Like Reply 2y Write a comment... CONFIDENTIAL - PROTECTED BY CONFIDENTIALITY AGREEMENT MT-IG-AG-00056864