The big issue: Mental health and the TikTok effect
Therapy Today, April 2023

‘SIGNS YOU HAVE ADHD’, the white text boldly proclaims over a red-tinted video in which two teenage girls dance erratically. More white text set against red speech bubbles appears on screen, delivering the wisdom that will tell you whether or not you too have attention deficit hyperactivity disorder:

‘Eat too much or eat too little.’
‘Not being able to listen when being spoken to.’
‘Having lots of new obsessions.’
‘Talk a lot and can’t sit still.’
‘Having RSD [rejection sensitive dysphoria].’
‘Trouble falling asleep at night.’
‘Getting hyperactive when understimulated.’
‘Getting good ideas but not going ahead with them.’

Welcome to TikTok’s mental health community – a place where everyone can create video content giving others advice on mental health issues, from anxiety to PTSD and everything in between. The account giving this advice belongs to neither a mental health professional nor someone well versed in healthcare, but an anonymous user with the account name random.tips.4u, who also gives advice on topics such as how to be popular in school (the answer, in case you were wondering, is ‘be nice to everyone’, ‘wear crop tops and jeans’, ‘wear your hair down’ and ‘wear lip gloss and mascara’).

TikTok’s rise to popularity has been meteoric since it launched internationally in 2017. TikTok is a free platform created and owned by the Beijing-based company ByteDance that provides templates to allow users to quickly and easily create and upload short-form videos, from 10 seconds to three minutes in duration, via their smartphones. The TikTok app had been downloaded 3.5 billion times worldwide as of January 2023. Official statistics show 43% of TikTok’s global audience as aged from 18 to 24 years old, with 32% of users aged 25 to 34,¹ but what’s less clear is how many children and young teens are among the regular users who spend on average 52 minutes a day on the app. It comes with a recommended lower age limit of 13, but according to Ofcom’s 2022 Children parents: media use and attitudes report, half of children from three to 17 used TikTok in 2021, making it the third most used social media platform of all (first being YouTube, the original short-form video platform, and the second, messaging app WhatsApp).² It also found that four in 10 five- to 16-year-olds used TikTok on a daily basis. Girls were more likely than boys to use TikTok regularly; one in three boys (34%) were daily users compared to half of girls (48%). 

What started out as a platform for entertainment has quickly grown into somewhere users go for information and advice, with hashtags such as #mentalhealth, #anxiety and #adhd racking up billions of views. With one in six children and young people in the UK now reporting mental health issues,³ and NHS mental health services overwhelmed with increased demand, it’s perhaps not surprising that mental health-themed content on the platform has taken off – why wouldn’t young people seek information and support through an app they enjoy using? And while the established video platform YouTube is also popular with young people, what has raised concerns about TikTok is its heavy emphasis on personalisation – as a user interacts with videos by watching, skipping, liking, commenting or sharing, TikTok’s algorithm learns what the user is interested in, and uses that information to recommend content to the user’s personalised ‘For You’ page. That means a young person who has shown interest in mental health-related content is likely to see more of the same every time they use the app. The question it raises for us as a profession is how much of this information is accurate and useful – and what is our role in dealing with the impact of being bombarded with it on younger clients?

Misleading

A 2022 study published in the Canadian Journal of Psychiatry analysing the top 100 most popular videos about ADHD on the platform found that 52% of them were classified as medically misleading, 27% were based entirely on personal experience, and only 21% were considered useful when compared against diagnostic criteria.⁴

A similar study published by medical health group PlushCare painted an equally disheartening picture.⁵ Five hundred TikTok videos that included the #mentalhealthtips and #mentalhealthadvice hashtags were analysed by medically trained professionals to assess the recommendations and advice for accuracy, and potential risk. The researchers concluded that 83.7% of mental health advice on TikTok is misleading, while 14.2% of videos include content that could be potentially damaging. Only nine per cent of those offering advice on the platform had a relevant qualification in the respective field, but 99% of videos didn’t have a disclaimer disclosing that the creator was unqualified to give mental health advice.

‘As with all social media, people who post and share information on the platform may have good intentions, but the content could be inaccurate, misleading or potentially dangerous in some cases,’ says Marie Chellingsworth, Senior Lecturer in Psychology at Arden University and a cognitive behavioural therapist. ‘For instance, a large amount of the mental health advice on TikTok includes generic tools such as practising “self-care” or going for walks for improving mental health. Although these activities are something that can aid in improving wellbeing overall, those suffering from a mental health condition may require tailored, individual treatments in line with clinical guidelines.’

Self-diagnosis

One of the more alarming potential consequences of this spread of misinformation is the rise in self- diagnosis. In my work for Kooth plc, an online digital therapy platform that provides anonymous support to 11- to 25-year-olds, I encounter adolescents on a near daily basis who are convinced that they have conditions such as ADHD, or are hearing voices in their head, after seeing someone their own age posting about it on TikTok. This has seemingly led to a wave of young people diagnosing themselves with everything from a minor neurosis to a full-blown psychosis, sometimes at the expense of seeking a formal diagnosis.

One of the more worrying TikTok trends is for young people to post videos introducing their multiple identities, referred to as ‘alters’, which have their own names, pronouns, styles, accents and mannerisms – some may even be animals, mythical creatures or hybrids. The trend has led to concerns about a potential rise in young people self-diagnosing with dissociative identity disorder (DID). ‘A number of mental health clinics across the country, including ours, have recently seen an influx of adolescents who are presenting with self-diagnosed dissociative identity disorder (DID) and claiming that within themselves there are a number of different personalities that emerge at different times,’ said US child psychiatrist Dr David Rettew in Psychology Today in March 2022. ‘Much of this seems to be driven by a small number of influential people on TikTok who have posted very popular videos in which they describe their DID in great detail.’⁶

During the pandemic, the popularity of videos demonstrating symptoms of tics and Tourette’s syndrome was linked with the increase of young people, especially young girls, seeking help for tics. One researcher called it ‘an example of social contagion or mass sociogenic illness’.⁷

But perhaps the biggest concern of all is the increase in self-diagnosis with ADHD, one of TikTok’s most popular hashtags with more than 14.5 billion views. Many of the videos posted under the hashtag – some of which have millions of views – offer ‘tips’ for ADHD diagnosis. Many of the most popular posters, such as Peter Hyphen with 485,100 followers and videos with titles such as ‘ADHD in girls’, have no professional qualifications. Dr Anthony Yeung and colleagues who analysed the 100 most popular videos on ADHD uploaded to TikTok comment that the hashtag #adhd is currently the seventh most popular health-related hashtag on the platform, and warn of the impact of the ‘romanticisation of mental health symptoms’: ‘The popularity of the platform appears to have contributed to increased awareness of attention-deficit/hyperactivity disorder (ADHD), with some individuals seeking a diagnosis after watching videos about ADHD on the platform. Although social media can reduce mental health stigma and improve health literacy, there is also concern about misinformation and the potential for illness/health anxiety (“cyberchondria”) due to the volume of unmoderated, user-generated content online.’

Sanam Naran, a South Africa-based counselling psychologist with 470K followers on her TikTok account @theconsciouspsychologist, agrees there are reasons for concern. ‘What I’ve noticed, especially with neurodivergent, autistic or ADHD people, is that a lot of them have self-diagnosed on TikTok, and while that is helpful for people who can’t access a psychologist, it’s not helpful in the sense that autism can sometimes look like complex trauma, or ADHD can sometimes look like bipolar. So you could be making the mistake of misdiagnosing yourself.’

TikTok is more far reaching and invites dialogue in a way that other platforms do not, points out US psychotherapist Dr Joe Kort, whose bio on his profile @drjoekort contains a prominent disclaimer for his more than 293K followers – ‘TikTok isn’t therapy’. ‘The risk is that people consider it therapy and it is not. The other risk is people believe everything that is being said when a creator might not be a leader in that area or even know that much,’ he says. ‘It might be more opinion than science and fact. We can’t stop creators who are uninformed from making videos but we can promote more responsibility on the parts of those who are following.’

Psychoeducation

But expecting ‘followers’ to take responsibility for assessing their mental health needs is a big ask when those followers are children – and the videos that come up on their ‘For You’ page are chosen to keep them coming back for more. For some professionals, the answer comes down to taking a ‘if you can’t beat ’em, join ‘em’ approach, by joining the platform to ensure there is robust and accurate content on the platform that young people can access. ‘I thought, I can sit in my therapy room and I can see one person at a time and I can complain about what’s going on out in the world,’ says Dr Julie Smith, a UK-based therapist and clinical psychologist with more than 4.2 million TikTok followers. ‘Or I could put something positive out there and increase the chances that anyone who’s vulnerable might come across my stuff — as opposed to other stuff that’s not going to help them.’⁸ Done well, posting on TikTok may also be a good career move, as Dr Smith’s recently published book spent several weeks at the top of the bestseller charts. In a recent interview, she puts her success down to meeting a demand for content from young people who ‘have very little confidence in their own ability to manage their mental health’.⁹

Dr Smith’s videos are typically 60 seconds long and use everyday items as props to explain concepts such as trauma – in one of her most popular posts she uses an inflated balloon to represent an event or feeling that a sufferer cannot bear to face. The video shows her pushing the balloon down into a tank of water to show the effort involved in suppressing trauma and the mess it creates when it forces its way back to the surface. In another, an overflowing bucket explains how stress works. She receives up to 1,000 messages a day on her posts, including many who say that a post inspired them to go to therapy.

As well as psychoeducation, the platform also has the power to destigmatise mental health issues, believes Sanam Naran. ‘I think TikTok is an amazing platform to break the stigma around mental illness and around therapy specifically,’ she says. ‘I think it’s a great tool for both practitioners and everyday people who are struggling with different mental health challenges to share their experiences, to talk about therapy and the mental health struggles they’re facing.

‘I think it’s important for us to share knowledge around different challenges that people face, especially if we’re finding recurring themes in our practice. For example, during COVID-19 there were a lot of cases of loss and anxiety, so I think it’s important to really use TikTok to psychoeducate people. But then I think it’s also important in the same breath to be using enough disclaimers and enough warning points to say “please don’t self-diagnose”.’

Peer support

Even a cursory glance at the mental health community that has sprung up on TikTok shows that the need for understanding, the challenging of stigmas, and a yearning to feel connected with others is something felt acutely by its younger users.

‘The sense of community that gets built around my page and around people who are experiencing similar challenges to the ones I speak about is incredible,’ says Naran. ‘They feel like they’re part of this community and have a sense of belonging, which is so important for loneliness, for depression, for anxiety and all of that.’

Marie Chellingsworth agrees that peer support can be hugely beneficial for young people, provided appropriate safeguards are in place. ‘Just knowing someone else is going through the same thing that you are can be really helpful for people, normalising and enabling them to feel hope.

‘The prevalence of mental health-related content on TikTok will undoubtedly have led to an increase in the general awareness of mental health conditions. Mental health advice on TikTok could also be a lifeline for someone who is suffering from a mental health condition and may feel uncomfortable reaching out for help. In this sense, despite the potential for inaccurate information, some of the more generalised advice given could pull an individual through a difficult period. In addition, for those who cannot afford therapy, self-help techniques seen on platforms such as TikTok may help, but it is important that these are evidence based, from a reputable source and appropriate to avoid potential harm.

With the platform’s success showing little sign of slowing down, it’s clear that TikTok won’t be going away soon. Whether or not a therapist feels they have the skills, time, or inclination to begin using TikTok to engage with young people is something only individual practitioners can answer, but the presence of qualified mental health professionals using the site could help foster a safer environment, says Chellingsworth.

'Another way the platform could raise awareness in a more positive way would be to invite regular content from qualified mental health professionals and those with lived experience of mental health problems to give appropriate advice, share accurate content and give people information about where help is available.’

And what else could TikTok do to help safeguard the mental health of young people?

TikTok currently uses human and artificial intelligence filtering as a way of managing inappropriate content. It bans content promoting suicide promotion, cyberbullying, self-harm and unhealthy weight loss; however, a risk is that not all filters pick up harmful content and users may change hashtags to enable these posts to still be shared. During the pandemic some social media sites were screening for false information and putting this onto posts being shared that were inaccurate regarding COVID; it would be great to introduce this for mental health and other false information that hasn’t been fact-checked,’ says Chellingsworth.

‘The site itself could also offer users a link to reputable mental health information and support sources and have this visible at all times. If the content was safeguarded effectively on TikTok – for example, warning viewers of potentially triggering videos or having a pop-up requirement for creators to disclose they are not qualified – it would ensure fewer individuals are exposed to misinformation. Pop-ups could also include a message to direct users to professional help and to utilise the platform positively without scaremongering and encouragement of incorrect diagnosis.’

Scepticism

In the meantime, we are also all in a position to counterbalance misinformation on a one-on-one basis with those clients who bring a self-diagnosis to a therapy session. For my Kooth clients, I try to encourage curiosity around a self-diagnosis, by asking if they think there’s a chance they could have something other than the condition they’ve decided on, and how they think it might impact them if their self-diagnosis turns out to be wrong.

It’s about doing what we always do, says Dr Rettew – ‘gather more 
information while being both supportive and validating, and at the same time holding a little scepticism about taking everything we hear at face value. We may find out for one youth that the DID symptoms really never were part of that person’s life before watching TikTok but that underlying the elaborate presentation are genuine feelings of anxiety and identity disturbance. For another person, maybe we find out that the DID symptoms have been present all along and it took TikTok to make the person feel safe enough to express them more openly.’

Therapeutic work, like the lives of our clients, is ever changing and always evolving. Whether you see TikTok as part of that evolution, a vital tool for connecting with those who need our help, or a dangerous gateway to misinformation, one thing is undeniable – it’s going to be having an impact on the young people we work with for some years to come.