Investigating mental health service user views of stigma on Twitter during COVID-19: a mixed-methods study.

Background: Mental health stigma on social media is well studied, but not from the perspective of mental health service users. Coronavirus disease-19 (COVID-19) increased mental health discussions and may have impacted stigma. Objectives: (1) to understand how service users perceive and define mental health stigma on social media; (2) how COVID-19 shaped mental health conversations and social media use. Methods: We collected 2,700 tweets related to seven mental health conditions: schizophrenia, depression, anxiety, autism, eating disorders, OCD, and addiction. Twenty-seven service users rated them as stigmatising or neutral, followed by focus group discussions. Focus group transcripts were thematically analysed. Results: Participants rated 1,101 tweets (40.8%) as stigmatising. Tweets related to schizophrenia were most frequently classed as stigmatising (411/534, 77%). Tweets related to depression or anxiety were least stigmatising (139/634, 21.9%). A stigmatising tweet depended on perceived intention and context but some words (e.g. "psycho") felt stigmatising irrespective of context. Discussion: The anonymity of social media seemingly increased stigma, but COVID-19 lockdowns improved mental health literacy. This is the first study to qualitatively investigate service users' views of stigma towards various mental health conditions on Twitter and we show stigma is common, particularly towards schizophrenia. Service user involvement is vital when designing solutions to stigma.