https://orcid.org/0000-0002-1019-9987
Abstract
Background
Online self-harming and suicidal behavior is a novel and rapidly increasing phenomenon warranting comprehensive mapping of used research methods.
Aim
To identify and map how knowledge on online self-harming and suicidal behavior is gathered, including how data are collected e.g. questionnaires and interviews.
Methods
The review follows the Joanna Briggs Institute Manual for Scoping Reviews in tandem with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. A keyword search of three electronic databases was conducted on two occasions, yielding 5422 records. Following duplicate removal, the records were screened based on the following inclusion criterions; (1) in English or Nordic language and published between 2011–2022, (2) presenting results for self-harming and/or suicidal behavior on social media and (3) using tools for either interview or questionnaire aiming at assessment of the experience of online self-harming and suicidal behavior from the perspective of the person who engages in the behavior. A total of 64 articles were included.
Results
45 used questionnaires, 17 used interviews, and two studies mixed the two approaches. 17% of the studies had made some effort to ensure validity within the questionnaires and 15.8% gave full access to the interview guide.
Conclusion
Research into online self-harming and suicidal behavior is characterized by a lack of validated measurements and methodological transparency. The results emphasize a need for further development, testing, and validation of questionnaires and greater openness and reflexivity in qualitative methodology to enable cross-study comparison and advance knowledge of this complex phenomenon.
Introduction
The high prevalence of self-harming and suicidal behavior across countries emphasizes that it is a worldwide public health problem and concern [Citation1–6]. As a result, research on self-harming and suicidal behavior has increased notably in recent years [Citation7].
However, neither self-harming nor suicidal behavior is unchanging [Citation8]. On the contrary, it constantly evolves into new forms, mainly influenced by social media, which constitutes an increasingly important part of our lives [Citation8,Citation9]. Consequently, through social media, self-harming and suicidal behavior can also occur online. This behavior is a new and poorly understood phenomenon, mainly due to its rapid evolution, technological development, and the notoriously closed online communities that young people tend to build when engaging in online self-harming or suicidal behavior [Citation10].
Though we do not fully understand what this new phenomenon is or involves, we do know that online self-harming and suicidal behavior has skyrocketed in recent years [Citation11] and encompasses the use of social media to harm oneself, e.g. by communicating condescending content about and to oneself via fake profiles [Citation12]. It can also involve seeking out conflicts on social media to be humiliated and consciously causing others to say vicious things about oneself. Furthermore, images are exchanged [Citation1] showing wounds, broken extremities, etc [Citation13]., and thoughts and feelings about suicidal actions, as well as concrete ideas and methods for both self-harm and suicidal actions, are exchanged. These closed online communities are known to exist on Instagram [Citation10], among other platforms, enabled by the possibility to create a so-called “Close Friends list” within which certain content can be shared only with a smaller group of people or simply by anonymous accounts following only similar profiles, so-called finstas, which is short for fake profiles on Instagram [Citation14]. Furthermore, online self-harming and suicidal behavior can occur in anonymous chat forums, also called servers, on Discord and other social media platforms with similar features.
Other aspects of self-harming and suicidal behavior are observed when young people engage in various challenges, such as the Blue Whale Challenge, Fire Fairy game, Cinnamon Challenge, and other online games, which are aimed at engaging in self-harming or suicidal behavior. These various online activities are associated with increased self-harming urges, suicidal ideation, and past suicide attempts [Citation15–18], while other studies emphasize that online self-harming and suicidal behavior is a double-edged sword that also contributes to reduced feelings of loneliness and increased access to peer support [Citation19]. A recent systematic review by Brennan et al. [Citation20] suggested that effects that are harmful for some can be helpful for others, which is supported by the findings of another review [Citation21].
Nevertheless, self-harming and suicidal behavior induced or mediated by social media is thus a novel phenomenon of increasing interest and, presumably, prevalence [Citation22], as evidenced by a rapid increase in the number of articles recently published. Therefore, a comprehensive description and mapping of used and available research methods and approaches is warranted. Examining how data are collected and systematically mapping methodologies are also imperative.
This review therefore aimed to identify how knowledge of how social media influences self-harming and suicidal behavior is collected, i.e. by describing characteristics of the validated tools used (e.g. questionnaires) and the transparency and rigor of qualitative studies employing interviews aiming to assess the experience of online self-harming and suicidal behavior from the perspective of people who engage in the behavior.
The secondary aims were to identify potential gaps requiring future research and to suggest initiatives to improve methodological quality.
Methods
This scoping review was conducted and reported following the Joanna Briggs Institute Manual for Scoping Reviews (JBI Manual) [Citation23,Citation24], including the recommendation that the updated JBI Manual [Citation24] is used in tandem with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [Citation23,Citation25,Citation26], to ensure both rigor and transparency of the review [Citation26].
Search strategy
A search string was formulated through consultation with a research librarian to search the databases PubMed, CINAHL, and PsycInfo on October 18th, 2021. The search was renewed on June 16th, 2022.
The search terms were as follows:
Self-harming and suicidal behavior: Self-harm, selfharm, selfmutilation, self-injury, selfinjury, self-injurious behavior*, focal suicide, parasuicide, suicide gesture, self-inflicted violence, self-wounding, self-abuse, non-suicidal selfinjur*, NSSI, NSSID, self-injury non-suicidal, self-destructive behavior, selfdestructive behavior, deliberate self-harm, deliberate selfharm, suicide, suicidal ideation.
Social media and internet: Social media, internet, World Wide Web, SoMe, Twitter, Instagram, Snapchat, Reddit, ASKfm, Facebook, YouTube, Tumblr, Pinterest, WhatsApp, Messenger, WeChat, QQ, Q-Zone.
The terms were combined with “OR” in each category and with “AND” between the categories. This search was supplemented by reviewing references of prior relevant reviews. The full search history is available in the Electronic Supplementary Material.
Eligibility and selection criteria
Because the literature referring to self-harming behavior uses different terms and definitions [Citation27], the review included both self-harming and suicidal behavior. Moreover, the motivation for performing self-harming behavior can be either non-suicidal or suicidal [Citation28], depending on the definition [Citation27]. Studies were included if they were (1) in the English or Nordic languages and published between 2011 and 2022. A preliminary search showed that relevant studies had been published in recent years and yielded quite a few hits. Furthermore, this range was chosen because this online phenomenon is constantly evolving due to technological developments and new social media apps including novel opportunities and features that can result in different online self-harming and suicidal behaviors. Additional inclusion criteria were (2) presenting results for self-harming and/or suicidal behavior on social media, including online games with a self-harming or suicidal agenda and interaction, and (3) using tools, either interviews or questionnaires, aiming to assess the experience of online self-harming and suicidal behavior from the perspective of people who engage in the behavior.
Studies that did not directly focus on experiences interacting on social media (e.g. those that involved coding of text messaging or covered other types of internet use or internet addiction, including Google searching, gambling, or cyberbullying) were excluded, as were intervention studies measuring the effect of an intervention and gray literature, including case reports, editorials, and books.
Screening
Two reviewers (MEH and LDØ) screened titles and abstracts for eligibility. When eligibility could not be determined by the titles and abstracts alone, the reviewers obtained and independently evaluated full-text versions of the articles. To increase consistency, the first 50 publications were screened and discussed prior to the final screening. Title/abstract screening was subsequently conducted independently to identify studies that potentially met the inclusion criteria. Full texts of the suitable studies were retrieved and independently assessed for eligibility. Any disagreements were resolved through discussion, and there was no need for the third reviewer (MN) to help reach a consensus. The screening of titles, abstracts, and full texts and the final inclusion of studies were performed in Covidence.
The process is depicted in .
Figure 1. Identification of studies on online self-harming and suicidal behavior.
Data extraction
Two reviewers (MEH and LDØ) independently extracted the data from each article. The included variables describing the transparency and rigor of the studies were as follows.
Characteristics
Title, author, year of publication, origin of data, objective, sample size, age and sex composition, setting, whether self-harming and/or suicidal behavior was investigated, and recruitment period.
Results for included studies using questionnaires
Which tool or single item was used, level of validation or self-validation, and which advantages and disadvantages were reported.
Results for included studies using interviews
Type and place of interview, whether interviewers were trained, scientific method, availability of interview guide, and which advantages and disadvantages were reported.
Due to the heterogeneity of the research questions, methods, and assessed outcomes of the included studies, the results of the present study are summarized and described in narrative form.
Results
Study selection
As seen in , 5422 articles were identified in the three electronic databases and uploaded to Covidence. After importation to Covidence, 1021 duplicates were removed, leaving 4401 articles for title/abstract screening. A total of 140 studies were retrieved as full texts, and 64 of those were eligible for inclusion. The most common reasons for exclusion were a lack of description of the interactions on social media (i.e. just descriptions of time spent online) and internet addiction, followed by a methodology lacking interviews or questionnaires.
Study characteristics
The 64 included studies were conducted predominantly in North America (n = 21), Europe (n = 17), and Asia (n = 15). The remaining studies originated in Australia (n = 10) and Africa (n = 1).
The included articles were published between 2011 and the first half of 2022, with more than 68% published in the last five and a half years. See for further details.
Figure 2. Timeline of the year of publication of the articles included in the study.
Most of the included articles (70.3%) used questionnaires [Citation1,Citation3–5,Citation9,Citation11,Citation12,Citation14,Citation15,Citation18,Citation22,Citation29–64] or interviews (26.6%) [Citation2,Citation13,Citation31,Citation65–79]. The methods of only two papers involved both tools (3.1%) [Citation5,Citation31]. These studies are described in .
Table 1. The included studies on online self-harming and suicidal behavior and the methods they used.
Table 2. The included studies on online self-harming and suicidal behavior and the questionnaires they used.
Table 3. The included studies on online self-harming and suicidal behavior that used interviews.
The 64 articles represented a total of 96496 participants, predominately female (69%) and aged younger than 25. The setting was stated in 50% of the studies, and the most common platforms investigated were Instagram and Facebook. A total of 39.1% of studies investigated online self-harming behavior, while 37.5% investigated online suicidal behavior, and 23.4% investigated both suicidal and self-harming online behavior. Self-harming and/or suicidal behavior was not explicitly stated in the objectives of 14 articles; however, their data collection tools, whether questionnaires or interviews, presented results specifically for self-harm and/or suicidal behavior on social media, and the authors assessed the experience of self-harm and suicidal behavior online from the perspective of people engaging in the behavior.
The proportions of questionnaires and interviews
In this review, questionnaires were found to be the most frequently used tools for data collection, with 70.3% of studies using them. Generally, few studies (8.5%) used a standardized tool, while the remaining 91.5% of studies used one or more self-developed questions, either isolated or as single-item add-on questions to existing questionnaires, targeting non-suicidal self-harm (NSSI), deliberate self-harm, or suicidal ideation or behavior.
Only one study stated that it involved a validated questionnaire explicitly addressing online self-harming or suicidal behavior [Citation47]. A further 17% of studies stated that they had implemented some effort to ensure self-validity, i.e. complete and present psychometric testing, comprehensive pilot testing, or other actions [Citation5,Citation9,Citation15,Citation17,Citation30,Citation33,Citation47,Citation80].
In total, 26.6% of the studies used interviews as a data collection method (29.6% including the two studies using mixed methodology). Most studies used semi-structured interviews (68.4%), followed by focus groups (15.8%), while the remaining studies used structured interviews (10.5%). One study combined focus groups with semi-structured interviews (5.3%). Most studies (89.5%) stated their analysis method, but, generally, the interview guide was not available in the text or the appendix, with only 15.8% of the studies providing full access to it. In comparison, 31.6% of studies described themes or gave examples of some of the questions embedded in the interview. However, the interview guide was typically neither described nor available (52.6%).
Given the absence of validated questionnaires, it was important to determine whether the authors of the newly developed questionnaires or single items discussed any advantages or disadvantages of the tools they employed. They mentioned advantages and disadvantages in only 10.6% and 40.4% of cases, respectively, while 8.5% of studies outlined both advantages and disadvantages of using these questionnaires. Some studies using various questionnaires emphasized that the benefits included the ability to shape the questions to their unique purpose and that they sought to include questions that were previously used in other studies or were based on questions from well-known, validated scales. In contrast, the disadvantages highlighted were (1) challenges with validity and reliability, (2) problems with missing variables, and (3) uncertainty about how participants understood specific words or phrases.
Disadvantages were reported in 15.7% of the studies using interviews as a data collection method and primarily addressed difficulties in differentiating between various types of internet, online self-harming, and/or suicidal behavior, as well as the chronology of behavior. Advantages were reported in 10.5% of such studies, which outlined very few advantages, e.g. that a few interviews provided non-verbal participation options, which worked well for younger participants.
Discussion
The present review elucidated the methods used to study firsthand experiences of online self-harming and/or suicidal behavior, i.e. questionnaires and interviews. In total, we identified 64 studies that included 96496 participants, predominately female and younger than 25, and addressed specific online behavior when engaging in online self-harming or suicidal behavior. Notably, men were underrepresented in most of the included studies, in line with another review of the topic [Citation21]. Furthermore, it was striking that no studies originated from South America. A review by Kuss et al. [Citation81], which aimed to summarize and examine studies published outside of Europe and focusing on internet addiction, was also unable to identify and include studies from South America. Kuss et al. suggested that the reasons for this might be (1) low socioeconomic level, (2) because the field receives less clinical and scientific attention in these countries, or (3) because internet access is insufficient to make problematic internet use a widespread problem [Citation81]. We agree that these reasons are plausible and, despite extensive searching, we did not find any studies from South America that met the inclusion criteria of this review.
The lack of validated questionnaires and disclosure of interview guides is the most important finding of this study. Overall, just one study used validated questions, and 17% of the included studies made some effort to ensure self-validity. Furthermore, in the included studies that used questionnaires, 43 different single items or questionnaires were used, leaving few opportunities for valid comparisons of studies or results, especially given that various measures often produce different results [Citation82]. This suggests a need for standardization that enables us to compare across studies. To the best of our knowledge, there is no validated tool that fully addresses this phenomenon, which several of the included studies also problematize [Citation15,Citation35,Citation45,Citation51]. Other studies have also recognized limitations in establishing reliability and validity [Citation14] and acknowledged that a more thorough set of questions might produce a different result [Citation49]. While there is a consensus on the need for a validated tool, it is more difficult to recommend what such a tool should include. In the future, such a validated instrument is likely to be developed. Still, it remains uncertain whether it is possible to develop a comprehensive tool or if it will require constant re-examination to ensure its relevance because the phenomenon will constantly evolve, primarily due to the launch of new apps with novel features.
Research on online self-harming and suicidal behavior is in progress worldwide. We, as researchers, should provide each other with the best foundation to help develop high-quality measurements, share interview guides for inspiration, and conduct high-quality research.
Additionally, the field could benefit from establishing network collaborations internationally. Such an initiative would contribute to an increased awareness of the urgent need for a clear definition and conceptualization of the phenomenon. It is a general problem within the field of self-harming and suicidal behavior that different parts of the world use different terms to refer to self-harm and that self-harm is sometimes used synonymously with suicide attempts [Citation14,Citation27,Citation28]. This pattern is also observed within the more specific field of online self-harming and suicidal behavior, in which clear definitions and terms are greatly needed, as Picardo et al. [Citation83] also emphasized in a recent systematic review. It would be highly beneficial and enhance the quality of research if researchers in this field could commit to developing and using one or more specific definitions of this online behavior and simultaneously focus on questionnaire validation and disclosure of interview guides.
It is important to develop guidelines for the benefit of people who engage in self-harming and suicidal behavior online due to the scope and severity of the phenomenon. The development of such guidelines is also highly relevant for clinicians, especially to disseminate knowledge about the phenomenon and thus allow them to ask questions and provide support, as well as to intervene when needed. However, the sparse existing evidence hinders the possibility of developing and conducting robust intervention studies and prevents health authorities from developing and implementing guidelines for this phenomenon that would benefit clinicians, society as a whole, and the people who engage in self-harming and suicidal behavior online.
Whether developing questionnaires or interview guides, people with lived experience should be included in the processes of designing studies and selecting methodological tools to accommodate the changing nature of the phenomenon and ensure insight into an online world known for its closed nature. Furthermore, most of the included studies involved participants under the age of 25. However, a recent Danish report found that 4% of Danes over the age of 18 had engaged in online self-harming behavior, with the highest prevalence among 18–34 year-olds, with as many as 10% admitting to having engaged in this behavior [Citation10]. These figures suggest that this phenomenon is not only prevalent among teenagers but also occurs among adults. It is therefore crucial to ensure high-quality qualitative and quantitative studies that include a broader age and sex range.
Strengths and limitations
To the best of our knowledge, this scoping review is the first to offer an overview of used and thus available methods in the field of online self-harming and suicidal behavior that focus on users’ perspectives, i.e. questionnaires and interviews. A scoping review is an adequate method for this investigation, considering the large scope and heterogeneity across studies.
Strengths of the review include its rigor; systematic definition of clear research questions; and complete, transparent, and reproducible (1) search strategy, (2) article selection, (3) data extraction, and (4) analysis, which followed the JBI Manual for Scoping Reviews in tandem with PRISMA-ScR.
Quality assessment was not performed, as it was not necessary to obtain answers to the research question, which is often the case due to the nature of scoping review objectives [Citation24, Citation84]. The scoping review fundamentally does not aim to synthesize evidence but rather to map and thereby provide an overview [Citation84], and the absence of a quality assessment is therefore not believed to have affected the quality of the current review.
Despite the review’s strengths, there are also limitations. Though the search strategy was as thorough as possible and was conducted in collaboration with a librarian, some studies might have been overlooked. First, we might have missed studies that were not available in the English or Nordic language. Second, due to the difficulty of selecting a definition of online self-harming and suicidal behavior, which has generally varied over time [Citation28,Citation82], it had to be discussed and adapted several times during the study period. Furthermore, the lack of a clear definition and conceptualization, in general and in the current study, means that it was difficult to classify the retrieved articles, so some articles might have been wrongfully excluded or included. Despite clear eligibility criteria being established prior to the screening of articles, they had to be debated and altered numerous times because we learned about the phenomenon during the study and became aware of behaviors that we did not know were possible at the beginning of the study. Third, the search strategy excluded gray literature. That decision might have meant that some measurements used in either clinical or research settings might have been overlooked. Fourth, one of the inclusion criteria was that the articles had to ask about online behavior and interactions related to online self-harming and/or suicidal behavior. However, due to a substantial number of the included articles not showing this clearly by disclosing the interview guide or the questions used in the various questionnaires, we had to judge this criterion using the results sections of the included studies. Therefore, some studies could have been wrongfully excluded or included.
Despite these limitations, the present results emphasize a need for using standardized methods in the field, which was also noted by a prior review in 2018 [Citation85]. We recommend (1) developing and testing generic questionnaires and (2) providing interview guides to help share ideas and gain more insight into what to ask, which is especially important due to the constantly changing culture of online self-harming and suicidal behavior. Fellow researchers have already called for these actions [Citation15,Citation35,Citation45,Citation51], which would increase the quality of methods in the field.
Conclusion
This scoping review revealed a paucity of validated, comprehensively tested questionnaires and a need for more transparency in qualitative studies. Specifically, there are needs for sharing interview guides to gain insight into what to ask and for questionnaire development and validation to ensure standardization within the field. This would allow us to perform cross-study comparison and evidence synthesis, although they might be challenging due to the changing nature of the phenomenon, which might be accommodated by including people with lived experience in the processes of designing studies and selecting methodological tools. Furthermore, there is a need for high-quality studies that include all ages and genders, as new Danish data suggest that online self-harming and suicidal behavior is also prevalent among the adult population, not only among adolescents.
Authors’ contributions
All authors have contributed significantly to the development of the study, while MEH, LDØ and MN were responsible for the screening. All authors participated in the analysis of the included articles, as well as in supervising MEH in the writing of the article.
Consent for publication
All authors have approved the submitted manuscript and provided consent for its publication.
Ethics approval and consent to participate
Not applicable.
Supplemental Material
Download MS Word (5 MB)Acknowledgments
A great thanks to librarian Jette Meelbye from the Health Sciences Library at the North Zealand Hospital for assistance with this review.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
All data generated or analyzed during this study are included in this published article and its supplementary information files.
Additional information
Funding
References
- Arendt F, Scherr S, Romer D. Effects of exposure to self-harm on social media: evidence from a two-wave panel study among young adults. New Media Soc. 2019;21(11–12):2422–2442. doi:10.1177/1461444819850106.
- Dardas LA, Price MM, Arscott J, et al. Voicing jordanian adolescents’ suicide. Nurs Res. 2021;70(1):E1–E10. doi:10.1097/NNR.0000000000000476.
- Dunlop SM, More E, Romer D. Where do youth learn about suicides on the internet, and what influence does this have on suicidal ideation? J Child Psychol Psychiatry. 2011;52(10):1073–1080. doi:10.1111/j.1469-7610.2011.02416.x.
- Seong E, Noh G, Lee KH, et al. Relationship of social and behavioral characteristics to suicidality in community adolescents with self-harm: considering contagion and connection on social media. Front Psychol. 2021;12:691438. doi:10.3389/fpsyg.2021.691438.
- Chen S, Lam T, Lam K, et al. Motivations for online expression, willingness of online help-seeking, and the risk of suicide among Hong Kong youths: a mixed-methods study. Cyberpsychol Behav Soc Netw. 2022;25(6):384–391. doi:10.1089/cyber.2022.0007.
- Vega D, Sintes A, Fernández M, et al. Review and update on non-suicidal self-injury: who, how and why? Actas Esp Psiquiatr. 2018;46(4):146–155.
- Lengel GJ, Styer D. Comprehensive assessment of nonsuicidal self-injury. 1st ed. Vol. 1. New York: Routledge; 2019. p.127–147. doi:10.4324/9781315164182-8.
- Ramluggun P, Small M. Understanding digital self-harm and its implications for mental health practice. Ment Health Pract. 20212021;25(1).
- Akkın-Gürbüz H, Demir T, Öszan B, et al. Use of social network sites among depressed adolescents. Behaviour & Information Technology. 2017;36(5):517–523. doi:10.1080/0144929X.2016.1262898.
- Larsen A, Krogh A, Oehlenschläger M, et al. Digital vold – delrapport om digital selvskade 2023. 2023.
- Lee S, Yim M, Hur J. Beneath the surface: clinical and psychosocial correlates of posting nonsuicidal self-injury content online among female young adults. Comput Hum Behav. 2022;132(1)
- Patchin J, Hinduja S. Digital self-harm among adolescents. J Adolesc Health. 2017;61(6):761–766. doi:10.1016/j.jadohealth.2017.06.012.
- Jacob N, Evans R, Scourfield J. The influence of online images on self-harm: a qualitative study of young people aged 16–24. J Adolesc. 2017;60(1):140–147. doi:10.1016/j.adolescence.2017.08.001.
- Charmaraman L, Hodes R, Richer AM. Young sexual minority adolescent experiences of self-expression and isolation on social media: cross-sectional survey study. JMIR Ment Health. 2021;8(9):e26207. doi:10.2196/26207.
- Nesi J, Burke TA, Lawrence HR, et al. Online self-injury activities among psychiatrically hospitalized adolescents: prevalence, functions, and perceived consequences. Res Child Adolesc Psychopathol. 2021;49(4):519–531. doi:10.1007/s10802-020-00734-4.
- Pritchard TR, Lewis SP, Marcincinova I. Needs of youth posting about nonsuicidal self-injury: a time-trend analysis. J Adolesc Health. 2021;68(3):532–539. doi:10.1016/j.jadohealth.2020.06.038.
- Frost M, Casey L. Who seeks help online for self-injury? Arch Suicide Res. 2016;20(1):69–79. doi:10.1080/13811118.2015.1004470.
- Khasawneh A, Chalil Madathil K, Dixon E, et al. Examining the self-harm and suicide contagion effects of the blue whale challenge on YouTube and twitter: qualitative study. JMIR Ment Health. 2020;7(6):e15973. doi:10.2196/15973.
- Dyson MP, Hartling L, Shulhan J, et al. A systematic review of social media use to discuss and view deliberate self-harm acts. PLoS One. 2016;11(5):e0155813. doi:10.1371/journal.pone.0155813.
- Brennan C, Saraiva S, Mitchell E, et al. Self-harm and suicidal content online, harmful or helpful? A systematic review of the recent evidence. JPMH. 2022;21(1):57–69. doi:10.1108/JPMH-09-2021-0118.
- Marchant A, Hawton K, Stewart A, et al. A systematic review of the relationship between internet use, self-harm and suicidal behaviour in young people: the good, the bad and the unknown. PLoS One. 2017;12(8):e0181722. doi:10.1371/journal.pone.0181722.
- Bell J, Mok K, Gardiner E, et al. Suicide-related internet use among suicidal young people in the UK: characteristics of users, effects of use, and barriers to offline help-seeking. Arch Suicide Res. 2018;22(2):263–277. doi:10.1080/13811118.2017.1334609.
- Peters MDJ, Marnie C, Tricco AC, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth. 2020;18(10):2119–2126. doi:10.11124/JBIES-20-00167.
- Peters M, Godfrey C, McInerney P, et al. Scoping reviews. In: Aromataris E MZ, editor. JBI manual for evidence synthesis. 2nd ed. Australia: JBI; 2020. p. 406.
- Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–473. doi:10.7326/M18-0850.
- Pollock D, Davies EL, Peters MDJ, et al. Undertaking a scoping review: a practical guide for nursing and midwifery students, clinicians, researchers, and academics. J Adv Nurs. 2021;77(4):2102–2113. doi:10.1111/jan.14743.
- Sutton J. Healing the hurt within: understand self-injury and self-harm, and heal the emotional wounds. 3rd ed. Oxford: how To Books; 2009.
- Nock MK, Favazza AR. Nonsuicidal self-injury: definition and classification. In Nock MK, editor. Understanding nonsuicidal self-injury: origins, assessment, and treatment. USA: American Psychological Association; 2009. p. 9–18. doi:10.2307/j.ctv1chrr2g.6.
- Aiba M, Matsui Y, Kikkawa T, et al. Factors influencing suicidal ideation among japanese adults: from the national survey by the cabinet office. Psychiatry Clin Neurosci. 2011;65(5):468–475. doi:10.1111/j.1440-1819.2011.02228.x.
- Branley DB, Covey J. Is exposure to online content depicting risky behavior related to viewers’ own risky behavior offline? Comput Hum Behav. 2017;75:283–287. doi:10.1016/j.chb.2017.05.023.
- Carey JL, Carreiro S, Chapman B, et al. SoMe and self harm: the use of social media in depressed and suicidal youth. Proc Annu Hawaii Int Conf Syst Sci. 2018;2018:3314–3319. doi:10.24251/HICSS.2018.420.
- Cheng Q, Kwok CL, Zhu T, et al. Suicide communication on social media and its psychological mechanisms: an examination of chinese microblog users. Int J Environ Res Public Health. 2015;12(9):11506–11527. doi:10.3390/ijerph120911506.
- Corcoran VP, Andover MS. Online disinhibition and internet communication of non-suicidal self-injury. Suicide Life Threat Behav. 2020;50(6):1091–1096. doi:10.1111/sltb.12659.
- Coulson NS, Bullock E, Rodham K. Exploring the therapeutic affordances of self-harm online support communities: an online survey of members. JMIR Ment Health. 2017;4(4):e44. doi:10.2196/mental.8084.
- Eichenberg C, Schott M. An empirical analysis of internet message boards for self-harming behavior. Arch Suicide Res. 2017;21(4):672–686. doi:10.1080/13811118.2016.1259597.
- Frost M, Casey L, Rando N. Self-injury, help-seeking, and the internet: informing online service provision for young people. Crisis. 2016;37(1):68–76. doi:10.1027/0227-5910/a000346.
- Gansner M, Belfort E, Leahy C, et al. An assessment of digital media-related admissions in psychiatrically hospitalized adolescents. APS. 2020;9(3):220–231. doi:10.2174/2210676609666190221152018.
- Harris IM, Roberts LM. Exploring the use and effects of deliberate self-harm websites: an internet-based study. J Med Internet Res. 2013;15(12):e285. doi:10.2196/jmir.2802.
- Harris KM, McLean JP, Sheffield J. Suicidal and online: how do online behaviors inform us of this high-risk population? Death Stud. 2014;38(6–10):387–394. doi:10.1080/07481187.2013.768313.
- Harris KM, Starcevic V, Ma J, et al. Suicidality, psychopathology, and the internet: online time vs. online behaviors. Psychiatry Res. 2017;255:341–346. doi:10.1016/j.psychres.2017.06.012.
- Kaukiainen A, Martin G. Who engages with self-injury related internet sites, and what do they gain? Suicidol Online. 2017;8:66–77.
- Keipi T, Oksanen A, Hawdon J, et al. Harm-advocating online content and subjective well-being: a cross-national study of new risks faced by youth. J Risk Res. 2017;20(5):634–649.
- Kingsbury M, Reme B, Skogen JC, et al. Differential associations between types of social media use and university students’ non-suicidal self-injury and suicidal behavior. Comput Hum Behav. 2021;115 N.PAG.
- Kirtley OJ, Hussey I, Marzano L. Exposure to and experience of self-harm and self-harm related content: an exploratory network analysis. Psychiatry Res. 2021;295:113572. doi:10.1016/j.psychres.2020.113572.
- Lewis SP, Michal NJ. Start, stop, and continue: preliminary insight into the appeal of self-injury e-communities. J Health Psychol. 2016;21(2):250–260. doi:10.1177/1359105314527140.
- Liu H, Liu S, Tjung J, et al. Self-harm and its association with internet addiction and internet exposure to suicidal thought in adolescents. J Formos Med Assoc. 2017;116(3):153–160. doi:10.1016/j.jfma.2016.03.010.
- Liu X, Huang J, Yu NX, et al. Mediation effect of suicide-related social media use behaviors on the association between suicidal ideation and suicide attempt: cross-sectional questionnaire study. J Med Internet Res. 2020;22(4):e14940. doi:10.2196/14940.
- Mars B, Heron J, Biddle L, et al. Exposure to, and searching for, information about suicide and self-harm on the internet: prevalence and predictors in a population based cohort of young adults. J Affect Disord. 2015;185:239–245. doi:10.1016/j.jad.2015.06.001.
- Mitchell KJ, Wells M, Priebe G, et al. Exposure to websites that encourage self-harm and suicide: prevalence rates and association with actual thoughts of self-harm and thoughts of suicide in the United States. J Adolesc. 2014;37(8):1335–1344. doi:10.1016/j.adolescence.2014.09.011.
- Mok K, Jorm AF, Pirkis J. The perceived impact of suicide-related internet use: a survey of young australians who have gone online for suicide-related reasons. Digit Health. 2016;2:2055207616629862. doi:10.1177/2055207616629862.
- Mok K, Jorm AF, Pirkis J. Who goes online for suicide-related reasons? A comparison of suicidal people who use the internet for suicide-related reasons and those who do not. Crisis. 2016;37(2):112–120. doi:10.1027/0227-5910/a000366.
- Nesi J, Wolff JC, Hunt J. Patterns of social media use among adolescents who are psychiatrically hospitalized. J Am Acad Child Adolesc Psychiatry. 2019;58(6):635–639.e1. doi:10.1016/j.jaac.2019.03.009.
- Nesi J, Burke TA, Caltabiano A, et al. Digital media-related precursors to psychiatric hospitalization among youth. J Affect Disord. 2022;310:235–240. doi:10.1016/j.jad.2022.05.013.
- Niederkrotenthaler T, Haider A, Till B, et al. Comparison of suicidal people who use the internet for suicide-related reasons and those who do not: survey study in Austria. Crisis. 2017;38(2):131–135. doi:10.1027/0227-5910/a000432.
- Record RA, Straub K, Stump N. #Selfharm on #instagram: examining user awareness and use of instagram’s self-harm reporting tool. Health Commun. 2020;35(7):894–901. doi:10.1080/10410236.2019.1598738.
- Sternudd HT. Photographs of self-injury: production and reception in a group of self-injurers. J Youth Stud. 2012;15(4):421–436. doi:10.1080/13676261.2012.663894.
- Sueki H. The effect of suicide-related internet use on users’ mental health: a longitudinal study. Crisis. 2013;34(5):348–353. doi:10.1027/0227-5910/a000201.
- Sueki H, Yonemoto N, Takeshima T, et al. The impact of suicidality-related internet use: a prospective large cohort study with young and Middle-aged internet users. PLoS One. 2014;9(4):e94841. doi:10.1371/journal.pone.0094841.
- Sueki H. The association of suicide-related twitter use with suicidal behaviour: a cross-sectional study of young internet users in Japan. J Affect Disord. 2015;170:155–160. doi:10.1016/j.jad.2014.08.047.
- Swedo EA, Beauregard JL, de Fijter S, et al. Associations between social media and suicidal behaviors during a youth suicide cluster in Ohio. J Adolesc Health. 2021;68(2):308–316. doi:10.1016/j.jadohealth.2020.05.049.
- Tseng FY, Yang HJ. Internet use and web communication networks, sources of social support, and forms of suicidal and nonsuicidal self-injury among adolescents: different patterns between genders. Suicide Life Threat Behav. 2015;45(2):178–191. doi:10.1111/sltb.12124.
- Vente T, Daley M, Killmeyer E, et al. Association of social media use and high-risk behaviors in adolescents: cross-sectional study. JMIR Pediatr Parent. 2020;3(1):e18043. doi:10.2196/18043.
- Villani D, Florio E, Sorgente A, et al. Adolescents’ beliefs about peers’ engagement in an online self-harm challenge: exploring the role of individual characteristics through a latent class analysis. Cyberpsychol Behav Soc Netw. 2019;22(11):684–691. doi:10.1089/cyber.2019.0002.
- Yom-Tov E, Brunstein-Klomek A, Hadas A, et al. Differences in physical status, mental state and online behavior of people in pro-anorexia web communities. Eat Behav. 2016;22:109–112. doi:10.1016/j.eatbeh.2016.05.001.
- Biddle L, Derges J, Goldsmith C, et al. Using the internet for suicide-related purposes: contrasting findings from young people in the community and self-harm patients admitted to hospital. PLoS One. 2018;13(5):e0197712. doi:10.1371/journal.pone.0197712.
- Brown RC, Bendig E, Fischer T, et al. Can acute suicidality be predicted by instagram data? results from qualitative and quantitative language analyses. PLoS One. 2019;14(9):e0220623. doi:10.1371/journal.pone.0220623.
- Brown RC, Fischer T, Goldwich DA, et al. ‘I just finally wanted to belong somewhere’ – qualitative analysis of experiences with posting pictures of self-injury on instagram. Front Psychiatry. 2020;11:274. doi:10.3389/fpsyt.2020.00274.
- Chen R, Wang Y, Liu L, et al. A qualitative study of how self-harm starts and continues among chinese adolescents. BJPsych Open. 2020;7(1):e20. doi:10.1192/bjo.2020.144.
- Ekpechu JOA. ‘… I really prepared to take my life …’: dynamics, instruments and suicidal thoughts among nigerian university students following social media reported suicides. Omega (Westport). 2020;86(1):338–360. doi:10.1177/0030222820969320.
- Gritton J, Rushing SC, Stephens D, et al. Responding to concerning posts on social media: insights and solutions from american indian and Alaska native youth. Am Indian Alsk Native Ment Health Res. 2017;24(3):63–87. doi:10.5820/aian.2403.2017.63.
- Laestadius LI, Craig KA, Campos-Castillo C. Perceptions of alerts issued by social media platforms in response to self-injury posts among latinx adolescents: qualitative analysis. J Med Internet Res. 2021;23(8):e28931. doi:10.2196/28931.
- Lavis A, Winter R. #Online harms or benefits? an ethnographic analysis of the positives and negatives of peer-support around self-harm on social media. J Child Psychol Psychiatry. 2020;61(8):842–854. doi:10.1111/jcpp.13245.
- Ozawa-de Silva C. In the eyes of others: loneliness and relational meaning in life among japanese college students. Transcult Psychiatry. 2020;57(5):623–634. doi:10.1177/1363461519899757.
- Padmanathan P, Biddle L, Carroll R, et al. Suicide and self-harm related internet use: a cross-sectional study and clinician focus groups. Crisis. 2018;39(6):469–478. doi:10.1027/0227-5910/a000522.
- Seko Y, Kidd SA, Wiljer D, et al. On the creative edge: exploring motivations for creating non-suicidal self-injury content online. Qual Health Res. 2015;25(10):1334–1346. doi:10.1177/1049732315570134.
- Teo AR, Strange W, Bui R, et al. Responses to concerning posts on social media and their implications for suicide prevention training for military veterans: qualitative study. J Med Internet Res. 2020;22(10):e22076. doi:10.2196/22076.
- Trnka R, Kuška M, Balcar K, et al. Understanding death, suicide and self-injury among adherents of the emo youth subculture: a qualitative study. Death Stud. 2018;42(6):337–345. doi:10.1080/07481187.2017.1340066.
- Weinstein E, Kleiman EM, Franz PJ, et al. Positive and negative uses of social media among adolescents hospitalized for suicidal behavior. J Adolesc. 2021;87(1):63–73. doi:10.1016/j.adolescence.2020.12.003.
- Zhu L, Westers NJ, Horton SE, et al. Frequency of exposure to and engagement in nonsuicidal self-injury among inpatient adolescents. Arch Suicide Res. 2016;20(4):580–590. doi:10.1080/13811118.2016.1162240.
- Khasawneh A, Chalil Madathil K, Zinzow H, et al. Factors contributing to adolescents’ and young adults’ participation in web-based challenges: survey study. JMIR Pediatr Parent. 2021;4(1):e24988. doi:10.2196/24988.
- Kuss DJ, Anne Marie HK, Lopez-Fernandez O. Internet addictions outside of europe: a systematic literature review. Comput Hum Behav. 2021;115 (2021): 106621.
- Faura-Garcia J, Orue I, Calvete E. Clinical assessment of non-suicidal self-injury: a systematic review of instruments. Clin Psychol Psychother. 2021;28(4):739–765. doi:10.1002/cpp.2537.
- Picardo J, McKenzie SK, Collings S, et al. Suicide and self-harm content on instagram: a systematic scoping review. PLoS One. 2020;15(9):e0238603. doi:10.1371/journal.pone.0238603.
- Munn Z, Peters MDJ, Stern C, et al. Systematic review or scoping review? guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):143. doi:10.1186/s12874-018-0611-x.
- John A, Glendenning AC, Marchant A, et al. Self-harm, suicidal behaviours, and cyberbullying in children and young people: systematic review. J Med Internet Res. 2018;20(4):e129. doi:10.2196/jmir.9044.