Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease that leads to significant impairment in functioning and health.1 The prevalence of AS has been estimated to be 0.32%–1.4% in different surveys.2,3 Living with the symptoms and consequences of AS, such as impaired physical functioning, pain and fatigue, could induce psychological disorders, such as depression. Mental health is affected in patients with AS, including an increased risk of depression when compared to the general population. Numerous studies have already shown that the prevalence of depression is higher in patients with AS when compared to the general population.4,5

The advance of the Internet is radically changing communication. The Internet has become an important source of information in parallel with the increase in its use in society. Obtaining online health information has become increasingly popular and people often use the Internet as a source of health information. The term ‘social media’ refers to the various internet-based networks that enable users to interact with others, verbally and visually.6 Social media has recently become part of the daily activities of many people. Many of them spend hours each day on Facebook, Instagram, Twitter, and other popular social media. Moreover, the number of social media users worldwide in 2019 was 3.484 billion, and up to 9% year-on-year.7 Studies have shown the benefits of enabling people to express their thoughts and feelings, and to receive social support. The impact of social media on individual or institutional communication, modernizing environment and knowledge acquisition is non-negligible in the era of digitization.8 Social media channels have gained an important place for knowledge and awareness of the diseases. Patients with rheumatic diseases are very eager to use internet to better understand their chronic diseases.9

The use of internet and social media are important instruments for effective education and communication. One of the beneficial aspects of thus in AS patients has been the use of social networks for better support in health-related coping, social interactions, and patient information processes. This study aimed to review the positive and/or negative effects of using internet and social media on depression in AS patients.

Demographic findings of the AS patients are shown in Table 1. The depression scores between the patients who used the Internet (12.18±6.85) and social media (12.35±6.90) were compared with those who did not (27.19±10.51 vs. 25.20±11.66) and a significant difference (p≤0.001) was found. Smart phone users were in the majority (73.5%). WhatsApp was the most preferred social network (66.5%), followed by Facebook (52.9%), Instagram (52.3%), Twitter (19.4%), and Pinterest (5.8%). The percentage of patients who use social media for searching about health-related information is 68.9%. Facebook was the most preferred social network for the information (45.9%). Information sources among social media users were following their rheumatologist and other healthcare givers and/or rheumatology patients. Social media users and non-users were similar according to their age, gender or educational status, and marital status. There were no significant differences between the type and duration of social media with the depression score. There were no differences in the prevalence of depression between users of the different social networks. Moreover, based on a cut-off of 3 types of social media, there was significant difference in the status of depression among patients (<3, n: 64, 14.71±6.77, vs. ≥3, n: 51, 10.47±6.45, p≤0.001). There was no difference in depression scores according to site, age, and number of households. A weak correlation was observed between the BASDAI/BASFI and BDI-IA depression variables (r=0.167, p=0.019; r=0.188, p=0.022, respectively). There was a significant difference among the severity of depression in terms of the use of social media (p≤0.001) (Fig. 1). Furthermore, social media had a positive effect on the severity of depression in patients who were using tumor necrosis factor inhibitors (TNFi) (p≤0.001) (Fig. 2). Of the Internet users, 41.2% did research on AS prior to their diagnosis, and 77.9% did research after their diagnosis. Moreover, 70.8% searched for the treatment online, and 36.6% of the TNFi users searched the internet prior to undergoing treatment.

Fig. 1.

Severity of depression in terms of the use of social media.

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Fig. 2.

Severity of depression in terms of the use of social media in patients using TNFi.

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The results of this cross-sectional study revealed that a great majority of the patients with AS owned at least one device to connect to the internet and was using at least one social media platform regularly. Facebook and WhatsApp were the most preferred social platforms. The most of patients used social media for health-related purposes. Furthermore, using social media for searching about health and medical treatment information had a positive effect on the severity of depression in patients who were using TNFi. Our study showed that using social media of AS patients have low depression scores. To our knowledge, this study was the first to shed light on the positive effects of the Internet and social media on depression in AS patients.

Several studies have already shown that depression is the most common comorbidity in patients with AS.4,12,13 Meesters et al. showed that the consultation rate for depression is increased by more than 60% in AS patients, with women having a somewhat larger increase in risk.5 The BDI has previously been used to assess depression in studies of rheumatic disorders. The diagnosis of depression in rheumatic diseases is important, because this psychological state may influence other outcomes, such as compliance with medication and disease activity.14

Reviewing the recent literature, it is notable that technology is becoming an important part of medical practice from diagnosis to treatment. One of the useful aspects of technology in rheumatologic diseases has been the use of social networks, for better support in health-related coping, social interactions, and patient informing processes.15 The Internet is being increasingly used as an important source of health-related information, particularly in chronic diseases.16 This study was the first to shed light on the positive effects of internet and social media on depression in AS patients. The grounds of this merit can be implied in a number of previous studies, such as patients with RA use the Internet for a variety of purposes, including looking up health information, and more than half of the North Americans with access to the Internet use it at least once a month as a source of health-related information.17

Exercise therapies are the cornerstone of the treatment of AS. Visual materials and videos help to learn accurate exercise methods. Kocyigit et al. investigated YouTube as a source of patient information for AS exercises. The authors concluded that YouTube can be considered as an important source of high-quality videos for AS exercises.18

On the other hand, Jeri-Yabar et al. showed that excessive social media usage was associated with depressive symptoms in university students. In this study, the authors concluded that a Twitter user was an associated factor for the development of depressive symptoms and that being a frequent Facebook user was actually a protective factor against depressive symptoms. This may have been because Facebook is more personal, and is based more on real-life friends, whereas Instagram or Twitter are not, and people receive more feedback and support from friends than on the other sites.19 Another study supported the conclusion that Facebook is not an associated factor for depression symptoms.20 In the current study, according to the number of social media users, the depression score was found to be lower in those who used 3 or more types of social media.

WhatsApp seemed to be preferred online application method in patients for communication. This can be due to the widespread use of WhatsApp, which is the most common mobile application in Turkey.21 Moreover, it has an advantage of better preserving privacy compared to other social media platforms.

Finding the most appropriate and commonly used social media may be an important concept for stewardship in health policies. Useful information shared in the media reduces the need for patients to visit the offices of physicians and hospitals, and also enables them to communicate easily with their trusted physicians. Sharing useful experiences and informing other patients can sometimes prevent unnecessary referrals to the hospital and physician offices. These can save on gasoline, travel costs, and time and shifts.22 It is also notable that sudden outbreaks of public health events results in huge challenges for health service systems. Recent experience of the COVID-19 pandemic has indicated that the necessity of online interventions, especially for mental health disorders, is ineluctable.23,24

Our study has limitations. Geography limited nature of our survey was the major limitation because there can be important variability due to political, economic, cultural, religious, and ethnic factor differences between countries. Access to information content of the disease, frequency of access and the type of page accessed were not evaluated. Our study was done before the Covid-19 pandemic era, and we could not re-assess our survey during the pandemic. Habits, opinions, and preferences are subject to change during pandemics, disasters, and war times.

This study was designed based on the BDI and reports the results based on it. There are clearly further research agendas here, which could fruitfully be pursed considering the other important criteria and depression scorings in the literature. Although this study provides evidence that using social media plays a significant role in the depression scores of AS patients. It should be noted that is had limitations and the ways in which future research might be enhanced. Considering the fact that some cultural variables might affect the outcome of research, further research in other countries and societies may be helpful to find out if the same results will be achieved.

S.U., N.C., I.P. made conceptualization of the study, data curation, interpretation of the data, wrote and adjusted the concept and drafting of the original manuscript.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The authors have no conflict of interest to declare.