Introduction

A large body of research has linked media portrayal of suicide to spikes in suicide rates [1,2]. This association may not be causal; however, there are strong concerns that extensive coverage of suicide reported in a sensationalised or glamourised way, especially celebrities suicides, or giving explicit details of self-harming methods is associated with increase in suicidal behaviours among vulnerable people–a contagion or ‘Werther’ effect [1,2]. Previous research has also warned about possible contagion effects related to suicide stories shared on social media sites like Twitter, especially if the suicide stories resulted in significant audience engagement [3]. Conversely, media stories emphasising recovery and capability to get over crises and suicidal behaviours can have a positive influence on vulnerable people–the Papageno effect–reducing their chances of engaging in such behaviours [2,4].

Non-suicidal self-injury [NSSI], defined as the ‘direct and deliberate destruction of body tissue in the absence of intent to die’ [5], is susceptible to social contagion effects in a similar manner, especially among young people [6]. Studies have related exposure to NSSI on traditional and online media with its onset and maintenance [6]. Suicidal and non-suicidal self-injury are clinically two different behaviours driven by different factors and motivations [5], yet they share some conceptual overlap–they both refer to forms of self-harm [7,8]. For the purpose of this research, we will use the term self-harm in a broad sense, to refer to thoughts and behaviours related to intentional self-injury (e.g. cutting oneself on purpose) without distinguishing between suicidal or non-suicidal intention [8].

Concerns have been raised about the proliferation of easy to access and largely unmonitored self-harm related content online, and whether it triggers or increases self-harming and suicidal behaviours offline [9,10]. Yet we have little understanding of how self-harm content online influences actual self-harm behaviours in vulnerable individuals [8,11].

Previous reviews suggest engaging with suicide or self-harm content online has both positive and negative effects [12–17]. Positive effects include reducing feelings of isolation, providing an online supportive community, distress relief, alternative coping methods and self-harming reduction tips. Negative effects include triggering self-harming behaviours, their perpetuation via normalisation and validation, sharing of self-harm methods, and tips for concealment. To date, reviews have focused on the effects of social media and the internet on suicide and NSSI [12,14–17] or self-harm in general regardless of intention [13], with half of reviews focused on young people [12,13,16]. Research in this field has been conducted using different methodologies, with primary research drawing on quantitative, qualitative and mixed methods with diverse research designs [16]. Diane [12] suggested a possible interaction effect between research design and findings, with qualitative and mixed methods studies showing a more positive impact of the internet on self-harm behaviours, compared to the more negative impact reported in quantitative studies.

These reviews [12–17] compiled and reviewed data from sites like Facebook, Twitter, YouTube, and other suicide-related internet forums. None of these reviews included any studies about self-harm or suicide on Instagram. With over one billion active monthly users [18], Instagram is one of the most popular social media platforms among young people [19,20], and a common platform for posting self-harm content [11,21].

Although text-only posts are allowed since 2018 [22], Instagram was originally designed to share pictures [23] and short-videos, standing out amongst other social media platforms because of its visual nature, ‘sign up to see photos and videos from your friends’ [24]. Instagram content can be tagged using key terms known as ‘hashtags’ (e.g. #selfharm). Hashtags allow users to search for and find content of interest and ‘connect’ with others with similar interests [25].

Instagram came under public pressure after several high profile cases of youth suicide were found to have shared and engaged with self-harm content on Instagram [26–28]. Instagram has acknowledged the issue and promised an increased focus on minimising harm from their platform [29]. Meanwhile evidence of the relationship between Instagram content and increased risk of self-harm behaviours is unclear and fragmented [21], a scoping review of the current evidence is needed. Scoping reviews allow for “reconnaissance” of an emerging field of research inquiry [30]. They bring together information from primary research and present it in a cohesive way, clarifying concepts and methods, identifying gaps, and informing next steps [31]. We aim to synthesise how self-harm or suicide content on Instagram has been studied, what we know about it, and identify gaps in the literature to inform future research in the field.

Methodology

Following PRISMA (S1 File) and Joanna Briggs Institute guidelines for systematic scoping reviews [31,32] we: a) specified a research question; b) elaborated a review protocol (see S2 File); c) identified and selected relevant studies; c) extracted the main data out of the selected studies (data charting); d) collated, summarised, and reported the main findings; e) summarised the strengths and limitations of the body of literature, and reviewed its quality. Findings are summarised narratively and on a table.

Results

The search yielded 304 articles, of which 133 remained after removing duplicates. The first author (JP) completed the initial search and carried out the first stage of the screening process for relevance, based on title and abstract. After applying the inclusion and exclusion criteria 10 articles remained [34–43]. Authors (JP, GJ, SM) independently reviewed the full articles and examined their reference lists. No further relevant articles were identified (Fig 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Articles selection.

PRISMA flow diagram of articles selection process [31].

https://doi.org/10.1371/journal.pone.0238603.g001

Studies characteristics and quality

The key characteristics and overall quality score of the reviewed studies are given in Table 1. All studies were published between 2016–2019 at an increasing rate every year. Based on first author, articles originated from US/UK (n = 5), Germany or Austria (n = 4), and Belgium (n = 1). Eight studies focused on Instagram only [34–41], while two examined self-harm across Instagram, Twitter and Tumblr [42,43].

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Key characteristics of included articles.

https://doi.org/10.1371/journal.pone.0238603.t001

Seven of the ten studies retrieved and described self-harm or suicide related content on Instagram [34,36,37,39,40,42,43]. One study assessed Instagram users’ awareness and use of the Instagram reporting tool for self-harm content [41]. Arendt [35] measured the relationship between exposure to self-harm content and users’ self-harm behaviours and suicidality offline, and Brown [38] explored whether online users’ acute suicidality could be predicted from their Instagram activity and language used in their posts captions.

All reviewed studies were high quality articles (see S1 Table for the detailed quality appraisal scores). Nine articles scored ten out of ten in overall quality [34–38,40–43], and Carlyle [39] scored nine out of ten. All reported adequate aims, good methodology, research design, sample, rigorous analysis, and clear and adequate findings, bringing valuable research contribution to the field. All openly acknowledged some limitations, typically limits to extrapolate beyond their purposive samples [34–38,40–43] or lack of Instagram users’ information [35,42,43]. In terms of ethical considerations, most studies report having IRB ethical approval [34,35,37,38,40–43] or having followed ethical guidelines approved by the ethics committee of the Association of Internet Researchers (https://aoir.org/ethics/) [36]. Carlyle [39] reported none of those. Instead they claimed that ‘because the study did not involve human subjects, it did not require ethical reviews.’

Discussion

Previous studies had shown that social media is a common platform for youth to post about self-harm or suicide [13,45]. Instagram is a key social media platform for young people [21], a group of particular interest for suicide and self-harm prevention [8]; however, there has been paucity of published research about suicide or self-harm on Instagram. This review shows that this is changing, and that a small corpus of good quality scientific literature is starting to emerge.

The actual prevalence of self-harm or suicide content on Instagram is unknown. Unveiling this would require access to the full pool of Instagram posts, something only feasible for Instagram itself. Instead, current studies retrieved different purposive samples of Instagram content, publicly shared with self-harm or suicide related hashtags. Studies reported finding self-harm or suicide related content in around 9–66% of their examined posts [34,37,39,42,43]. The different quantity of self-harm or suicide content reported across studies is to be expected, given studies sampling and methodological differences. Some study samples included any Instagram post tagged as #self-harm, in a broad way, regardless of its actual content [43], others focused only on pictures of cuts [36,37], or reported how many of their sampled users recalled having seen suicidal content on Instagram [38]. Studies use different search terms, which return different amount of self-harm content (e.g. German NSSI-hashtags showed to retrieve greater proportion of actual NSSI-content than its counterpart in English) [36]. The date when the content was collected also matters, as Instagram made changes to its content policy regarding self-harm [21,29].

Altogether, studies used different approaches to research suicide or self-harm on Instagram. We distinguished between ‘content studies’ and ‘users studies’ depending on their sample and how they collected their data. ‘User studies’ contacted Instagram users directly, using surveys and online semi-structured interviews, to ask them about different aspects in relation to self-harm or suicidal content on Instagram [35,38,41], in some cases also mining their Instagram activity and personally uploaded posts captions [38]. Instagram ‘content studies’ collected publicly posted content tagged with different suicide or self-harm related hashtags on Instagram, without the actual users’ involvement in the process (or even being aware of it). Some examined hashtags, some pictures only, and some pictures and captions together as whole posts, with some including other users response to such content [34,36,37,39,40,42,43]. One study used AI to automatically distinguish pictures of NSSI-cuts from not NSSI-pictures, and used it to quantify and compare the amount of actual NSSI-pictures associated to different self-harm and suicide related hashtags in English and German [36].

Studies varied in their approach to analyse their data. Content studies typically used descriptive content analysis to code and characterise self-harm or suicide content. Studies used different coding protocols, but in general reported the amount of self-harm content present among their sample, with some also including audience responses, content time trends, or quantifying Instagram ability to identify such content [34,36,37,39,40,42]. Only Shanahan [43] offered a thematic description of self-harm content on Instagram and social media. All these content analysis studies relied on inter-coders agreement for reliability. Moreno [40] detailed a method that adds data triangulation, to foster rigour and validity in the coding of online content.

Survey studies carried out regression model-based analysis [35,41] and Brown [38] used quantitative linguistic inquiry to analyse users’ language on Instagram.

A previous review about self-harm and suicide online suggested the possibility of interaction bias between study designs and study outcomes, by which qualitative studies tended to find self-harm content online to be less problematic than quantitative studies [12]. In our review most studies using content analysis showed concerns about the proliferation of suicide or self-harm content on Instagram, whether such content and the community of users around it may normalise and reinforce self-harming behaviours, or even maybe facilitate social contagion among vulnerable users [35,39,34,37,40,42,36]. Only Shanahan [43] thematic study concluded that we should not over-worry about self-harm content online, that it is an avenue for expressing difficult emotions, more than a glamorised incitation to self-harm. However, only one study actually looked into the relationships between engaging with self-harm content on Instagram and self-harm or suicidal correlates offline [35]. It reported cross-sectional and preliminary longitudinal negative effects on self-harm and suicide-related outcomes offline [35]. Still, authors were cautious not to claim causal exposure effects. Whether people are at greater risk of self-harm because they engage with such content online, or rather they end up engaging with it because they were at greater risk for self-harm to begin with (reverse causality) cannot be ruled out based on the current evidence. Other confounders may be driving such relationship [35]. This is a common limitation of survey studies in the broader field of research [2,9]. However, Arendt’s study [35] adds to the voices raising concerns about harmful effects of self-harm content online, including compelling data about potential for copycat effects.

Terminology was another source of heterogeneity. Terms like self-harm, deliberate self-harm, self-injury or non-suicidal self-injury are all used to refer to similar (if not the same) behaviour, and they are often used interchangeably. This reflects the lack of consensus over terminology use more broadly in the field of suicide and self-harm research generally [5,46]. This is relevant because terminology can have methodological implications, influence study findings, and their interpretation. For example using #selfharm or #suicide to retrieve posts, and assume to study NSSI or suicide on Instagram [34,37,39,40]. Brown [37] coded as NSSI all pictures of wounds tagged with self-harm-related hashtags in German. Yet, Carlyle [39] found that the majority of #suicide-tagged posts also mentioned self-harm. Accurately distinguishing between suicidal or not suicidal self-harm behaviours and content is important because they are different things; however, this can be challenging [47]. When examining self-harm content online, unless we know more about the people posting it and their motives, distinguishing between self-harm content that is suicidal or non-suicidal is highly problematic [43]. In future research, one strategy might be to use the term ‘self-harm’ in a broad sense, to refer to behaviours and intentional acts carried out on oneself, knowing that they would cause pain or harm, regardless of suicidal intention, excluding alcohol abuse, smoking and other recreational drug use, and accidental harms to oneself [48].

Studies seem to agree that self-harm content represents users’ experience of distress [34,43]. The nature of such content is diverse, but most often it involves depictions of cuts. Compared to other social media, Instagram was found to host the greatest proportion of visual self-harm content [42]. This is relevant because previous research has suggested that imagery and visual content may have greater impact on users than text, it is more appealing, attracts more attention and may have greater triggering potential [45,49]. We found that self-harm content on Instagram elicits high levels of audience engagement, especially the more graphic and explicit it is [37,39].

Similarly to previous studies about pro-eating disorders content on Instagram [50], our review found that self-harm and suicide content on Instagram is typically shared using self-harm-specific hashtags, around which online communities emerge [40]. Such hashtags are designed to avoid Instagram censorship and this appeared to be effective [40]. Surveillance methods drawing on hashtag and captions to identify self-harming content do not appear to be very effective [40]. Moreover, Instagram’s tool for users to report negative content has not been widely adopted [41]. New technologies such as AI automatic image recognition offer a possible solution [36] and Instagram is looking into their implementation [21].

Strengths and limitations

This is the first review of primary studies around self-harm and suicide content on Instagram. Our search strategy was limited to English-language publications, but was not limited to any particular age group, despite the usual adolescent age focus of previous internet reviews [12,16]. Our review did not include grey literature as we focused on peer-reviewed publications due to their scientific quality and likely replicability. Our quality appraisal of the current literature provides a good proxy of the overall quality the field as a whole.

Implications and future research

There is self-harm content on Instagram. Although scarce, most research to date has focused on describing it. Most scholars show concerns about such content [34–37,39,40,42], however, there may also be some benefits for those who engage with it [15,43]. How self-harm content on Instagram relates to users self-harm risk and behaviours offline has been understudied, but researchers are starting to look into it and explore the factors underlying this relationship [35]. More research is needed to expand this line of inquiry [21,35]. Future research should move on beyond mere description of Instagram content.

Brown [38] showed that looking at the online activity and content of those sharing self-harm or suicidal posts on Instagram alone was not enough to accurately identify those at higher risk of suicide. Only by directly chatting with the posters themselves were they able to distinguish those with current versus past suicide ideation [38]. Accurate, reliable information about the users engaging with self-harm content online is needed [35,42,43]. We need more qualitative research, directly approaching online users who engage with such content, to obtain reliable users’ information, and better understand what in their views constitutes self-harm content online, why they engage with it, how it affects them, and relates to them offline. We need to understand this online phenomenon from the users’ perspective. At the same time, research could examine the potential of positive narratives and content, as suggested by the potential of the Papageno effect, to focus on users’ experiences of getting through suicidal crises and self-harming behaviours [4]. As in the broader field of suicide and self-harm research, consensus and correct use of self-harm terminology is needed. Finally, consensus around good ethical practises in this field of research is needed. Some content studies undergo IRB review [34,37,40,42,43], some do not [36,39]. Previous guidelines back IRB exception for observational studies of social media content (under certain conditions) [51]. However, given the sensitive nature of the content typically reviewed by studies in this field of research and ongoing social debate about online privacy and data ownership, whether publicly shared content on social media is of public domain is up for discussion.

Supporting information