Social Networking, 2013, 2, 185-192
http://dx.doi.org/10.4236/sn.2013.24018 Published Online October 2013 (http://www.scirp.org/journal/sn)
Evaluating Displayed Depression Symptoms on Social
Media Sites
Megan A. Moreno1, Erin Kelleher2, Megan Pumper1
1Department of Pediatrics, University of Washington, Seattle, USA
2Department of Pediatrics, University of Wisconsin, Madison, USA
Received July 18, 2013; revised August 23, 2013; accepted October 10, 2013
Copyright © 2013 Megan A. Moreno et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Social networking sites (SNSs) are immensely popular and allow for display of personal information, including refer-
ences to depression. Evaluating displayed content on a SNS for research purposes requires a systematic approach and a
precise data collection instrument. The purpose of this paper is to describe one approach to the development of a re-
search codebook for depr ession so that others may develop and test their own codebooks for use in SNS research. The
depression SNS research codebook was grounded in ethics, theory and clinical criteria. The key elements in the code-
book developmental process included an iterative team approach to develop variables of interest and data collection
sheet layout. Training protocols involve coding practice and reliability assessments. Interrater reliability remains a
critical assessment tool. Codebook successes include consistently high interrater reliability. Challenges include time
investment in coder training, SNS server changes, and social or cultural norms regarding public displays of mental
health. We provide detailed information about a systematic approach to codebook development so that other researchers
may use this structure to develop and test their own codebooks for use in SNS research. Future directions for the code-
book include expanding areas of interest such as anxiety or other depression evaluation criteria, and expansion to other
SNSs such as Twitter.
Keywords: Component; Formatting; Style; Styling; Insert
1. Introduction
Social networking web sites (SNSs) may present new op-
portunities to investigate depression, particularly among
adolescents and young adults. The vast majority of ado-
lescents and young adults use a social networking site
such as Facebook [1-3]. SNSs allow members to build a
personal web profile, to communicate with others and to
build a social network. Profile users may incorporate text,
photos, graphics, audio and video to build a personal re-
presentation of their identity.
Through content displayed on a SNS profile, profile
owners may give researchers and health care providers
insight into aspects of their behavior that are not always
apparent in offline life. These disclosures may include
references to depression symptom in the form of “status
updates,” personally written text describing the profile
owner’s current experiences. Previous work found that
approximately a quarter of publicly available Facebook
profiles of undergr adu ates d isplayed d ep ressio n sympto m
references, and a small proportion of profiles displayed
depression symptoms in patterns consistent with the Di-
agnostic and Statistical Manual (DSM-IV) criteria for a
major depressive episode (MDE) [4,5]. Additionally, dis-
play of depression symptoms was positively associated
with reporting depression symptoms using a clinical
screen [6].
Why might a profile owner display feelings of depres-
sion in such a public online venue? Previous work illus-
trates that computers elicit higher levels of self-disclo-
sure and uninhibited personal expression compared to
offline interactions [7]. Adolescen ts report that they o ften
disclose more about themselves on SNSs than they do in
person [8]. Further, the social risk hypothesis suggests
that humans try to minimize social risks in order to
maintain ties to a group [9]. It has been posited that peo-
ple with depression will change their behaviors to make
“safer” social decisions in order to avoid social failures.
Thus, social networking websites may present a venue to
those with depression th at feels safer for expressing emo-
tion durin g per i ods of isolation.
C
opyright © 2013 SciRes. SN

M. A. MORENO ET AL. 186
These online displays of health risk behaviors are im-
portant as they give health care provider s and r esear cher s
new insight into adolescent health concerns that are
clearly linked to morbidity and mortality among this po-
pulation. The most common form of depression within
the adolescent and young adult age group is major depre-
ssive disorder, which has a yearly incidence of approxi-
mately 8% [10,11]. Additional 22% of adolescents and
young adults suffer from “sub-diagnostic” levels of de-
pressive symptoms [12]. Both those with a major de-
presssion diagnosis and those with depression symp-
toms experience impaired functioning and morbidity [13 ].
Adverse outcomes of depression include increased rates
of substance use, co-morbid psychiatric conditions and
suicide [14-17].
Despite the prevalen ce of depression in th is popu lation,
college students struggling with depression symptoms
are frequently undiagnosed as many students do not per-
ceive a need for help or do not seek clinical services [10,
11,18]. While 30% of college students report feeling so
depressed in the past year that it was difficult to func-
tion, only 10% of co llege students repo t seeking an y type
of mental health care in the past year [19,20]. Concerns
about the stigma related to mental illness are also associ-
ated with less perceived need for help and decreased
treatment seeking behavior [21]. Recent media stories
highlight tragic suicides of young adults that were refer-
enced on Facebook prio r to being carried out; illustratin g
the urgent need to better understand the validity of dis-
played references to depression and other mental health
concerns [22]. Thus, social media could provide an in-
novative and complementary approach towards early
identification of depression.
Barriers to evaluation of social media for displayed
depression disclosures include concerns about subjectiv-
ity in coding or bias in evaluation of social media sites.
Thus, in order to establish SNSs as a credible approach
for understanding depression displays, a framework for
consistency and reliability in evaluation and measure-
ment of SNS profiles is essential. The purpose of this
paper is to describe one approach to the development and
use of a research codebook to evaluate adolescents’ dis-
played references to depression symptoms on Facebook.
Our intention is to provide a framework on which re-
searchers or clinicians may further develop and adapt
their own codebooks for use with mental health SNS
research. Given that SNSs may rise and fall in popularity,
our goal is to provide a framework that is usable and
adaptable to researchers as new technologies and new
mental health topics of interest emerge over time.
Foundation of the Codebook
In developing the codebook, we began with a review of
salient literature to contribute to the foundations of the
codebook’s theoretical, methodological and clinical
foundations. We first investigated theoretical models to
guide its structure so that we could understand the role of
SNSs in adolescents’ lives. The Media Practice Model
describes that adolescents choose and interact with media
based on who they are, or who they want to be, at the
moment [23]. This model influenc ed our early interest in
viewing SNSs as representations of adolescents’ identi-
ties and is supported by literature that suggests that ado-
lescents may disclose more about themselves in online
venues than they do face-to-face [24].
Codebook development was further influenced by a
review of the literature for qualitative methods. As
qualitative data can provide rich data, sometimes called
“thick description,” of experiences or events we wanted
to maximize the reliability in collecting and interpreting
such data [25]. We followed other investigators’ strate-
gies for interpreting qualitative interview data, such as
holding frequent team meetings to discuss and refine the
coding structure as it evolved [25,26].
Finally, in developing codes for references of depres-
sion we consulted established clinical criteria: the Diag-
nostic and Statistical Manual of Mental Disorders (DSM-
IV) [4]. By grounding the coding scheme on clinical cri-
teria, our goals were to maximize the clinical app lication
of data obtained via SNSs and to promote translation of
findings into further clinical research. Further, we wanted
to provide robust and detailed criteria that coders could
apply during each profile evaluation, so that coders did
not need to apply personal or subjective judgment to dis-
played content. Thus, references to depression symptoms
were defined using the DSM-IV symptom criteria for a
MDE [4].
2. Codebook Development
2.1. Confidentiality
In creating the codeboo k, a first objective was to address
ethical concerns that may arise in evaluating data from
SNS profiles. Consistent with recommendations by the
Institutional Review Board, a priority area was to de-
velop protocols towards maintaining confidentiality of
the data obtained from prof iles. This focus on con fidenti-
ality was applied to the data collection stage. Th e coding
protocol specified that data recorded from profiles would
never be identified by name but by an assigned code
number. Confidentiality protoco ls have also been applied
to presentation of data through papers or at conferences.
For example, when presenting direct text quotes from
participants’ profiles, quotes are always slightly altered
so that an online text search will not match the quote to
the participant’s profile. Further, no other identifiable
information is documented with text examples. If names
are displayed with in the text they are taken out and re-
placed with the label of “profile owner” or “friend”.

M. A. MORENO ET AL. 187
2.2. Profile Security
SNS profiles may be “publicly available” such that pro-
file content is accessible by the entire online social net-
work, or “privately available” in which profile content is
only available with explicit permission of the profile
owner. Many early studies focused on SNS profiles that
were publicly available [27,28]. In the past few years,
both privacy settings and the culture of privacy on Face-
book have changed, and many users favor settings that
limit public access. However, findings from one study
illustrated that many participants were open to allowing
their profile content to be accessed by researchers [29].
Thus, researchers may consider asking participants to
Facebook “friend” a research assistant to allow content to
be mutually viewable between the research team and the
participant.
2.3. Defining Variables of Interest
To develop a coding scheme for the complex variable of
depression, we used an iterative process. The first step
was establishing clinical criteria to operationally define
depression symptoms. References to depression symp-
toms were defined using the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV) symptom criteria
for a Major Depressive Episode (MDE) [4]. The criteria
for MDE included depressed mood, loss of interest/
pleasure in activities, appetite changes, sleep problems,
psychomotor agitation or retardation, energy loss, feeling
worthless or guilty, decreased concentration or suicidal
ideation [4].
Thus, text references were considered a depression
symptom reference if they fit one of the depression crite-
ria by keyword or a synonym. For example, one symp-
tom keyword of major depression is “hopeless,” there-
fore a status update stating “I feel hopeless” would be
coded as a reference to depression. The term “giving up”
is a synonym of “hopeless,” therefore, a status update
disclosing “I feel like giving up” would be coded as a
reference to depression as well. Status updates that
clearly referenced a person other than the profile owner
(i.e. “Molly is sitting next to me in class and she looks
sad”), or references to the common situ ation al expe rience
of having a bad day (i.e. “I’m having a depressing day”)
were not considered depression references.
The next step involved applying these coding criteria
to the SNS of choice; initial codebooks were developed
to be applied to Facebook. Applying these clinical crite-
ria to a pilot sample of profiles resulted in identification
of further keywords and synonyms linked to the variable
of interest. Team discussions of both findings from pro-
file content, as well as notes on the evaluation process
itself followed. If modifications were suggested, the
process began again with the coding of a practice set of
profiles and then presenting findings and notes on the
process to our research group. This process helped fur-
ther develop the coding schemes.
2.4. Preparing the Codebook
Following this iterative process, the codebook protocol
was created. This included documentation prompts for
each proposed depression symptom including: a descrip-
tion of the va riable including any relevant clinical criteria,
a list of example terms that represented the variable and a
list of example terms that might be considered but that do
not represent the variable. Please see Table 1.
Table 1. Examples of mental health references.
DSM-IV Criteria for Depression Examples of Key Words/Phrases Don’t Include:
Depressed mood Sad, empty, crying, tearful, alone, lonely, sad face emoticon“I had a bad day”, “FML”
Decreased interest or pleasure in
activities Not having fun, do n ’t feel like doing anyth in g , giving up
Increase or decrease in appetite No appetite, don’t feel like eating, can’t stop eating,
eating everything i n sight
“I ate too much at McDonalds this weekend”,
references to poor eating habits rather than
changes in appetite
Sleep problems Sleeping too much, slept more than 10 hours, fatigue,
tired, exhausted
Psychomotor agitation or
retardation Pacing, repetitive behaviors, feeling slow
Loss of energy Can’t get anything d o n e , no motivation
Feelings of guilt, worthlessness,
negative self-appraisal Feels guilty or worthless, “I’m so stupid”
Indecisiveness Can’t decide on something, don’t feel like deciding,
can’t ma ke u p mind
Recurrent thoughts of death or
suicidal ideation Thinking of ways to commit suicide, references to
jumping
Difficulty concentrating Can’t study, can’t finish work, can’t concentrate Don’t want to concentrate, can’t concentrate
because of activity (TV, friends, Facebook)

M. A. MORENO ET AL. 188
We then established details of the protocol. These in-
cluded in what time period the profile should be evalu-
ated. For example, many profile owners have had a
Facebook profile for several years; investigators using
the codebook would need to know how far back in time
to conduct a profile evaluation. The codebook protocol
also included instructions regarding which comments on
the SNS profile should be evaluated (comments from the
profile owner only versus comments from other users
that have posted on that profile owner’s wall).
The codebook data collection sheets were then out-
lined. The data collection cells were designed so that
sections of the profiles (i.e. information section, profile
wall) would be evaluated in the same order each time a
participant’s profile was coded. Variables in the code-
book were presented in the codebook in the same pre-
scribed order that the coder follows during the profile
evaluation process .
2.5. Codebook Layout
The codebook was initially designed in Microsoft Ex-
cel®. Excel data sheets allowed separation of layers of
the codebook onto several separate excel sheets within
one excel file. The layers included the following: 1) the
codebook protocol and coding criteria, 2) the data collec-
tion sheet with variables on the horizontal axis, allowing
for participant data to be entered across each individual
row, 3) the form for coders to track questionable refer-
ences to discuss with the team, as well as document the
outcome of the team’s discussion regarding those refer-
ences. Table 2 includes an example section of a data
collection sheet including demographic information and
references to depressive symptoms.
2.6. Coding Procedure
Coders follow several steps with each profile that is
evaluated. First, the “information section” of the profile
is viewed to obtain demograph ic information. Second, to
evaluate depression symptom disclosures, investigators
review each profile’s status updates from the predeter-
mine d s tar t d ate up through the current date of evalu ati on .
Each status update is evaluated. For each status update
that includes a depression symptom reference, coders
assess whether the displayed symptom meets one of the
DSM-IV criteria for a MDE [4]. If the displayed symp-
tom meets criteria, the coder recorded the date of the
disclosure, verbatim text and the depressive symptom in
which the verbatim text was correlated. The next status
update is then evaluated.
2.7. Adaptation of the Codebook
The initial depression codebook was designed to be ap-
plied to Facebook profiles. Over time, our research in-
terests have included evaluation of Twitter pages given
the rise in popularity of this SNS [30]. For each adapta-
tion of the codebook, the same iterative process is ap-
plied including application of relevant clinical criteria,
development of an initial set of keywords to apply to
profiles, evaluation of a practice dataset, and discussion
with the team to further refine the codebook. We con-
tinue to routinely communicate with our IRB and re-
search ethics colleagues to maintain the highest standards
of integrity in our data collection and reporting ap-
proaches. Further, we have examined applying our code-
book to other data storage systems such as Filemaker©.
We have found that using software like this is particu-
larly helpful when recording longitudinal data or larger
sample sizes.
2.8. Coder Training
The training of coders who will use the codebook follows
a similar process that was used in codebook development.
Coders are first trained in the ethics of human subjects
research, and provided additional training in the impor-
tance of confidential procedures in SNS and mental
health research. Second, coders learn the theoretical
foundation and diagnostic criteria that underlie the vari-
ables of interest. Coders are then trained to use the code-
book through several hands-on sessions in which coders
practice evaluation of profiles and active participation in
discussion is encouraged. After these sessions, coders
begin applying the codebook to practice sets of profiles.
Coding is first done with a mentor to provide real-time
feedback, and then practiced alone with a review of cod-
ing afterwards with that same mentor. Coders are en-
couraged to take their time to fully understand the proc-
ess of profile evaluation and the theoretical basis under-
lying the codebook. Coding training can last up to 3
months before coders participate in a formal research
project.
Interrater reliability is a critical parameter for the cre-
dibility of the codebook. Our procedure includes selec-
Table 2. Example of a data collection page in the codebook.
PPT ID CODER
INITIALS DATE GENDER AGEDepression symptom Date 1 Depression symptom Text 1 Depression symptom Type 1
001 CK 10/12/12 F 20 10/5/12 Hate my life… 1,2
002 CK 10/12/12

M. A. MORENO ET AL. 189
ting a 20% random sample of profiles to be evaluated by
all coders. This process is done approximately every 2
weeks during coder training, and can be used to identify
individual items in the codebook that are vague or need
clarification. It can also be used to identify coder trainees
who would benefit from additional training. During each
research study, interraters are assessed at specified inter-
vals. Cohen’s Kappa statistic is used to evaluate the ex-
tent to which there was overall agreement in the coding
of the presence or absence of depression symptom refer-
ences on a profile. In our previous work, Cohen’s kappa
was 0.79 for depression symptom references [5].
3. Special Concerns
In the coding of health behaviors on SNSs, there may be
instances when concerning displays are identified which
suggest that the profile owner’s safety is at risk. It is
critical to determine your research team’s approach to
how such concerning disclosures will be handled, and to
train coders so they are prepared to deal with worrisome
situations that may become apparent when coding. In
coding depression, suicidal ideation or threat was a major
concern for our group. In response to this concern, we
developed a suicide protocol to manage any suicidal ref-
erences that may arise.
In developing a response protocol for any specific area
of mental health, it is advisable to first identify what ma-
jor areas of concern may be encountered while coding
this behavior. Examples may include suicidal ideation, or
disclosures of abuse or neglect. Second, the times in
which it may be crucial to intervene if such disclosures
are noted must be designated. This is important because a
worrisome disclosure may be time stamped anywhere
within the last week to one year ago. Third, a plan re-
garding how a coder will respond if these issues are pre-
sent must be developed. This intervention may be in the
form of a phone call, email, or text message sent by the
coder, the principal investigator, or another designated
person. The coder may be asked to provide mental health
resources, or alert appropriate authorities. Last, this plan
must be readily available to all research team members.
A brief outline of an example protocol is available as
Figure 1.
4. Discussion
4.1. Codebook Successes and Challenges
Our codebooks have undergone considerable adaptation
over the past five years. The iterative process has con-
tributed to adapting codebooks to account for new vari-
ables of interest as well as new trends and structural
changes among SNSs. However, this ongoing process of
codebook development has required time, patience and
team commitment. Development and maintenance of a
codebook leads to challenges inherent in team research:
the need for coordination of schedules and tasks to ac-
commodate frequent meetings, the time required to reach
group consensus. The time required in training a new
team member as a coder is substantial, when a team
member needs to periodically or permanently relinquish
their involvement in projects this can impact the overall
productivity of the team.
Another challenge has been adapting to changes within
SNSs. One example was changes in Facebook layout in
2011. During an ong oing study, we found that the layout
of Facebook changed to a “Timeline” format and addi-
tional types of information were added, such as a “cover
photograph.” This led to modifications to our codebook
Code
•R eference found on profile, ie. " going to end it all, "writing to s ay goodbye", "ready to
jump off a cliff"
Contact
•I f reference is displayed in p ast 2 days-phone and alert medical personnel
•I f reference is in pa st 30 d ays and recent displays are not worrisome-email/sns
message
•I f reference is greater than 30 days old-review wit h team to decide if contact is needed
•Make a plan to deliver necessary care, can have participant or assist part icipant in
contacting: crisis hotline, family member or friend, and/or couselingservice
Care
Figure 1. Key elements of suicide protocol.

M. A. MORENO ET AL. 190
determine how best to consider newly available data in
our assessments. Further, upgrades to SNSs can lead to
server outages and changes in how search engines func-
tion within the website, which may impact access to
Facebook as well as challenges in locating particular
profiles.
A final challenge has been adap tation to the social and
cultural norms that are found in a particular study popu-
lation. These norms contribute to behavioral expectations
defined with a group and are often present on SNS. For
example, a challenge for coders may be to interpret ref-
erences that may be meant as sarcasm in a certain social
group, or may have an unclear context from an outsider’s
perspective. Providing a systematic way to address these
questions by discussions and group consensus is a key
strategy, but requires time and scheduling. Additionally
cultural norms about mental health, for example, may
affect a particular culture’s display of depression symp-
tom references on SNS. Certain cultures may be im-
pacted by social stigma in that culture against displaying
any signs of mental illness. This may be easier to acco unt
for if the investigators conducting the coding are from
the same social or cultural demographic of the owners of
the profiles, however this is not always be possible. It is
important to be able to identify these social and cultural
norms and consider how they may affect the displays
being evaluated. Our team has found it particularly bene-
ficial to have input from people in the demographic being
studied as contributors to codebooks and partners in in-
terpretation of data.
4.2. Future Codebook Developments
Despite these challenges, our codebook development
process has been both rewarding and beneficial. We will
continue to revise and adapt our codebook as new re-
search questions arise and new trends in social media use
emerge.
This paper has focused on development of depression
coding criteria based on clinical standards. This stan-
dardized approach can be applied to the development of
codebooks for other areas of mental health towards
achieving a consistent and reliable assessment tool. An
example of the application of this codebook development
method includes developing a codebook to evaluate cog-
nitive vulnerabilities, previously applied to diary entries
[31]. The cognitive v u lnerab ility co d ing ap pro ach or co n-
tent analysis of verbatim explanations (CAVE) was de-
veloped in 1984 by Seligman and colleagues [32]. The
coding approach assesses cognitive vulnerabilities which
may be a precursor for depression symptoms [33]. In this
coding approach, each text disclosure is examined for
both an event and attribution, which are then categorized
as internal versus external, global versus specific, and
stable versus unstable. The text disclosures describing a
more internal, global, and stable state are considered
more indicative of depression. After applying the steps
outlined in this paper, our team recently pilot-tested this
coding approach on status updates on Facebook and
tweets on Twitter. We encountered challenges in identi-
fying status updates and tweets that included both an
event and an attribution due to the text references being
short in length and lacking detail, but we were able to
apply this coding scheme to a small percentage of status
updates and tweets on both sites. This example illustrates
how other content analyses strategies can be adapted to
SNS codebooks following the steps outlined in this pa-
per.
4.3. Future Research Approaches
We believe that SNSs may provide new opportunities to
increase student help-seeking behavior. It is possible that
such screening could be triggered by the content of a
SNS profile. When Facebook users view their profile,
advertisements triggered by keywords present on the
profile are displayed at the side of the profile. It is possi-
ble that university counseling centers could link mes-
sages about counseling services or links to online scree-
ning to keywords such as “depressed” or “hopeless”.
There are reasons to believe that online counseling may
be an acceptable approach in this digitally savvy genera-
tion, a recent study evaluated an interactive web-based
program designed to screen students for depression and
suicide risk. After the initial online screening, 24% of
students entered into an online dialogue with a counselor,
19% later attended an in-person session with the coun-
selor and 14% entered a treatment program [34]. SNSs
may provide an innovative venue to provide access to
online scre ening and follow-up re sources.
Given the difficulty in identifying students at risk for
depression, and the potential negative consequences of
untreated depression, is it imperative to embrace innova-
tive public health opportunities to reduce the burden of
mental illness in this population. However, any SNS in-
tervention ideas hinge on designing programs that are
acceptable to students and respect their privacy and con-
fidentiality [35,36]. Mental health disclosures are per-
sonal and potentially stigmatizing, thus, proper attention
to privacy will be essential. However, there are reasons
to be optimistic that today’s college students may wel-
come online mental health progr ams. A study assessing a
web-based intervention program found that among stu-
dents with an un-met need for mental health care, over
90% reported interest in or intention to use the program
[37].
In conclusion, it is our hope that this paper will pro-
vide detailed information about one systematic approach
to mental health codebook development so that other
researchers may use this structure to develop and test

M. A. MORENO ET AL. 191
their own codebooks for use in mental health SNS re-
search. It is not our intent to present this paper as the
only way to develop or use a codebook; rather, we hope
to assist other researchers in adapting this process to fit
their own areas of interest.
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