Motivations, Experiences, and Perceived Consequences of Repeated Mental Health–Related Content Creation on Social Media: Reflexive Thematic Analysis of Chinese Young People

Introduction

Social media has been deeply involved in the daily lives of the younger generation [1]. The China Internet Network Information Center reported that 98.7% of young people aged 14 to 35 years are social media users, 62.3% of whom spent an average of more than 3 hours per day [2]. Growing up in the era of rapid mobile Internet development, the current generation of young people increasingly depends on social media for emotional expression, social connection, and information seeking by posting or interacting with others’ posts [3].

The transition from adolescence to adulthood exposes young people to multiple pressures related to academic, career, financial, and interpersonal relationships [4], resulting in a high prevalence of mental health issues [5]. In China, these pressures intersect with family and social contexts surrounding mental health. For instance, poor parent-child communication and academic pressure have been strongly associated with depressive symptoms among adolescents, while stigma and family expectations may constrain mental health disclosure and informal support in relationships [6]. Social media, therefore, has become an accessible and private platform for releasing distress and sharing experiences that may be difficult to discuss offline. Platform affordances may further shape this process. For example, Xiaohongshu (Rednote), a recommendation-driven lifestyle platform widely used by young people, combines algorithmically curated content distribution with personal narrative sharing; recent studies have shown that emotionally vulnerable and depression-related self-disclosures can attract engagement and validating responses from other users [7,8]. Consequently, there has been a rise in mental health–related content across social media platforms [9], posted by individual users describing their own lived experiences of depressive or anxious feelings, psychiatric symptoms, personal experiences of treatment, hospitalization, medication use, recovery from mental disorders [10,11], and self-harm, suicidal ideation, or behavior [12].

Prior studies have mostly focused on highly sensitive content, particularly self-harm or suicidal behavior, or on the presence of any relevant posts [13]. These captured isolated episodes, often under extreme circumstances, and neglected the fact that a mental health condition is a long-term status characterized by relapse and fluctuation. However, mental health–related content creation may unfold as a connected and iterative process involving motivation, creation, posting, audience response, and subsequent creation [14]. Griffith and Stein [15] analyzed mental health posts from 14,626 Tumblr users and distinguished the effects of self-expression from the reception effects of audience responses. They found that the more community feedback creators received, the more frequently they tended to disclose information in the future. Another study revealed that audience comments, requests, and engagement metrics can shape subsequent content strategies, self-evaluation, and relationships with followers [16]. This evidence suggests that audience responses may become part of the conditions shaping creators’ subsequent content creation. Examining mental health–related content creation as an integrated and repeated process may, therefore, provide a more complete understanding of how its perceived benefits and risks develop across ongoing interactions. However, little is known about this process among young people who repeatedly create content across broader mental health topics.

In addition, posts about emotional distress, psychiatric symptoms, treatment, and recovery from mental health disorders seem to be more common, easily resonated with by individuals with similar experiences, and therefore frequently attract substantial engagement, apart from sensitive topics [17]. However, less is known about the entire process among young people who repeatedly create broader mental health–related content.

To address these gaps, this qualitative study aims to explore how young Chinese creators experienced and made sense of repeated mental health–related content creation as an interconnected process, including why they posted, how they personally experienced creating and sharing it, and how these experiences affected their emotions, everyday lives, and subsequent content creation.

Methods

Ethical Considerations

This study was approved by the Institutional Review Board of the Affiliated Brain Hospital, Guangzhou Medical University (number 2024-105). Informed consent was obtained from participants before the interview, and parental consent was provided for minor participants. Participants who completed the interview received an incentive of RMB 100 (approximately US $15) as compensation.

Study Design

We conducted anonymous online semistructured interviews with participants recruited through major Chinese social media platforms. The reporting of this study was guided by reflexive thematic analysis (RTA) reporting guidelines [18].

Participant Recruitment

Purposive sampling was applied to recruit participants with varied experiences from December 2024 to March 2026 through recruitment advertisements posted by the official accounts of our department on major Chinese social media platforms. The poster introduced the study and research team, described the eligibility criteria and study procedures, stated the participant compensation, and provided the research team’s contact information (email address and working phone number). The English version of the poster is provided in Multimedia Appendix 1.

Eligibility criteria were (1) aged 15 to 34 years [19]; (2) use of at least one social media platform, including Weibo, Douyin, Rednote, Zhihu, Douban, and Bilibili (descriptions of the platforms are provided in Multimedia Appendix 2); (3) having posted at least 5 original, lived experience–based mental health–related posts within the previous 12 months as an individual user [20] and having received comments or direct messages from others; and (4) ability to participate in an interview of at least 30 minutes. Eligible posts included individuals’ own experiences of negative affect, psychiatric symptoms, mental health care and treatment, psychological counseling, self-harm, or suicide. Mental health professionals, including psychiatrists and psychological counselors, and content published by hospitals, institutions, or other organizational accounts were excluded. Individuals interested in participating contacted the research team directly and were asked to provide a screenshot of their social media profile. A formal psychiatric diagnosis was not required. Eligibility was based on participants’ lived experiences and the content and frequency of their mental health–related posts. Research staff manually reviewed publicly available posts to verify the posting criterion and assessed the remaining eligibility criteria. Social media profiles and posts were reviewed solely for eligibility screening and were not included in the qualitative analysis. Eligible individuals were then provided with further information about the study aims, interview procedures, expected duration, confidentiality, and compensation before informed consent was obtained.

Interview Procedures and Data Collection

The semistructured interview guide was developed based on the aim of this study and included participants’ personal and social media contexts, motivations for posting, experiences of creating and sharing content, and responses to audience feedback. It was adjusted after 2 pilot interviews in December 2024. These pilot interviews resulted only in minor revisions, and no core interview domains or substantive questions were added or removed. The final semistructured interview guide is provided in Multimedia Appendix 3, which served as a flexible prompt for data generation. Open-ended questions and follow-up probes were used to allow participants to elaborate on issues they considered important. The interviews were conducted online via Tencent Meeting by an investigator who was trained in qualitative methods (XT).

Data collection and preliminary analytic engagement proceeded iteratively, with the lead researcher (XT) reviewing transcripts as interviews accumulated. This judgment took into account the focused study aim, specificity of the participant group, quality of the interview dialogue, and the in-depth interpretive analysis planned. XT considered interviews sufficiently in depth when participants moved beyond brief descriptions to provide detailed examples, explain the meanings they attributed to their experiences, and describe how experiences unfolded or changed over time. Richness was considered in terms of the range, complexity, and variation of accounts across participants, including both recurring and contrasting perspectives. Recruitment ended after 20 interviews (including 2 pilot interviews) when XT judged that the dataset provided sufficiently detailed and varied accounts to support a coherent and multifaceted interpretation of the research questions. Participants’ legal names, identification numbers, home addresses, and workplaces were not collected for analysis, and social media profile links and contact information were not entered into the dataset or linked to interview responses. Audio recordings were downloaded after each interview to hospital-managed computers or servers, after which the cloud recordings were deleted from Tencent Meeting. Deidentified transcripts and analytic files were labeled using study IDs only and stored within hospital-managed systems with access restricted to authorized research personnel. Original audio files are retained for the period required by the institutional review board after study completion and are subsequently disposed of according to institutional requirements.

At the beginning of each interview, demographic characteristics (age, gender, occupation, and living status) and social media use information (daily use time, duration, main platform in use, and number of followers) were collected using a brief structured questionnaire. After an initial open-ended question about daily life, participants were asked about previous mental health care and treatment, including what diagnosis or clinical label they had been given during clinical care. Clinical characteristics, including mental disorder diagnosis, time since first diagnosis, psychiatric hospitalization history, current medication use, and medication adherence, were subsequently extracted from the interview transcripts. These clinical histories were all self-reported and were not independently verified through medical records or structured diagnostic interviews.

Data Analysis

Categorical characteristics were described as n (%) and continuous variables as mean (SD) or median (IQR; range). Interviews were audio-recorded, transcribed verbatim, and analyzed in Chinese to preserve linguistic and cultural meanings. HZ translated quotations into English, and XT checked the translations against the Chinese transcripts for conceptual equivalence.

RTA, adopting the approach by Braun and Clarke [21,22], was applied for qualitative analysis, as it enabled an interpretive examination of patterned meanings across social media creators rather than predefined hypotheses [23,24]. XT, who conducted all interviews and led the qualitative analysis, has a doctoral degree in epidemiology and medical statistics, received training in qualitative research, and is currently a postdoctoral researcher in public mental health. Her academic and research background informed her interest in mental health experiences on social media and sensitized her to recurring patterns and variation across participants’ accounts, while her public mental health perspective encouraged attention to the broader interpersonal and social contexts in which these experiences occurred. XT also had no prior relationship with the participants. During analysis, XT familiarized herself with the transcripts through repeated reading and then recorded reflexive analytic notes about important and interesting information related to the research aim, which were subsequently used to generate initial codes.

The analysis adopted an experiential orientation within a contextualist epistemological position. Participants’ accounts were treated as meaningful expressions of their subjective experiences while recognizing that these accounts were situated within interpersonal, cultural, and social media contexts. Coding was predominantly inductive and primarily semantic, while theme development involved interpretive work to construct patterns of shared meaning across participants’ accounts. Codes were iteratively reviewed, revised, and clustered into candidate subthemes, which were then organized into broader candidate themes. Candidate themes were reviewed against the coded extracts and the full dataset and refined according to their central organizing concepts. XT also developed successive thematic maps to document changes in the thematic structure. Other investigators (DW, RY, RW, and YL) reviewed selected transcripts and engaged in reflexive analytic discussions to consider alternative interpretations and refine theme boundaries. These discussions were used to challenge assumptions, consider alternative interpretations, and deepen theme development rather than establish coding agreement. The qualitative analysis was conducted using NVivo (version 15.0; Lumivero).

Methodological rigor was considered in relation to credibility, dependability, confirmability, and transferability. Credibility was supported through repeated engagement with the dataset, team-based analytic discussions, and participant quotations supporting the interpretations. Dependability was supported through reflexive analytic notes and successive thematic maps documenting the developing analysis. Confirmability was approached through transparent links between the data and the analytic account, with candidate themes repeatedly reviewed against coded extracts and the full dataset. Transferability was supported through detailed reporting of the recruitment setting, participant characteristics, social media context, and study procedures [25].

Results

Participant Characteristics

A total of 20 women with a mean age of 21.8 (SD 3.6) years completed interviews lasting 39 to 64 minutes; 60% (n=12) were students. Although a formal psychiatric diagnosis was not required for eligibility, all 20 participants subsequently reported during the interviews that they had received a clinician-assigned mental health diagnosis or clinical label. Based on participants’ self-reported clinical histories, 50% (n=10) reported a depressive disorder, 35% (n=7) reported a bipolar disorder, and 15% (n=3) reported receiving the clinical label “anxiety and depressive state.” Further, 80% (n=16) reported current psychiatric medication use. Rednote was the primary platform for 70% (n=14) of participants. Detailed information on participant characteristics is provided in Table 1.

Qualitative Thematic Findings

We developed 3 interconnected themes regarding how repeated mental health–related content creation became meaningful and changed through audience feedback in an iterative process. First, fulfilling emotional needs and making illness experiences meaningful through posting described how posting enabled participants to express, preserve, and make sense of their mental health experiences and transform these experiences into support for peers. Second, audience feedback reshapes emotional experiences and subsequent creation captured how responses from others changed the emotional meaning of posting and became part of the conditions shaping later content creation. Finally, disclosing mental illness requires emotional effort and boundary management indicates the efforts involved in making vulnerable experiences visible while managing emotional burden, audience boundaries, conflict, and unwanted contact in the virtual world. Together, the themes connect motivations, experiences during and after posting, and participants’ perceived consequences. The diagram of themes and subthemes is shown in Figure 1.

‎

Theme 1: Fulfilling Emotional Needs and Making Illness Experiences Meaningful Through Posting

Overview

Across participants’ accounts, posting mental health–related content was more than sharing difficult experiences with others; it also provided a way to manage experiences that were hard to express or understand in daily life offline. Distress could, therefore, be released in a more controllable way, as posts could be anonymous and deleted whenever participants wanted. Illness experiences could also be preserved and sometimes transformed into knowledge or support that was useful to peers facing similar challenges. These functions were connected by a shared process of making difficult mental health experiences more manageable and meaningful through posting.

Seeking Recognition and Support When Offline Relationships Felt Insufficient

Participants described posting mental health–related content as a way to express emotional distress and seek recognition when social support in their offline relationships was perceived as unavailable or insufficient. Here, offline relationships refer to preexisting real-world relationships, such as those with family members, friends, or classmates, including both face-to-face interactions and direct private communication through phone calls, text messages, or online platforms. That is, care and support from family and friends might not necessarily be absent, but there was a mismatch between what they provided and the recognition participants needed. Family members and friends could be caring but minimize psychological distress, misunderstand mental illness, or be unsure how to respond. P13 (the 13th participant), for example, explained that their parents interpreted their distress as “a rebellious phase during puberty” and did not consider mental illness to be as serious as physical illness.

Against this background, social media provided access to external social support from peers or even strangers through posting mental health–related content. P11 described this experience during a particularly isolating period:

(I posted such content because) I’ve encountered some trouble in my life and that made me quite painful. The thing is, being alone is so lonely. I feel the emptiness inside that I can’t really describe. So I was desperately expecting support even from strangers to tell me that it would be okay. When I have someone to connect with, like chatting with others, time passes much more easily. Even a single positive response to my posts will make my day.
[P11, aged 21 years, Rednote]

P11’s account suggests that the anticipated value of posting did not necessarily lie in receiving practical advice or resolving the underlying problem. Even a brief response could function as recognition that distress had been noticed, temporarily interrupting feelings of loneliness. Posting, therefore, functioned as a low-threshold bid for connection when offline support felt insufficient, difficult to access, or emotionally costly. Nevertheless, it is worth noting that participants did not state that online support was a complete substitute for support from the real world. P11 was trying to “stay peacefully with myself in the reality and regain energy to share my everyday life rather than just focusing on my emotions and mental illness.”

P16, a 21-year-old Rednote creator, reduced posting after she entered a supportive relationship. This provided the converse pattern: when some of this relational need was met offline, the need to seek it through posting diminished. Together, these accounts position posting within participants’ broader ecology of support rather than as a simple preference for online interaction.

Expressing Negative Affect in a More Private and Controllable Way

For some participants, posting on social media was a way to express emotions without the interpersonal demands of direct disclosure. They reported a stronger urge to create and post when negative moods intensified. Compared with disclosing distress directly to people around them, posting was more immediate and controllable, since they could express their feelings to an unknown audience and later delete the content without concern about imposing an additional emotional burden on others.

P4 described posting during sleepless nights when their emotions felt particularly difficult to contain:

You can tell from the timestamps that I tend to post late at night, because I can’t fall asleep due to my bad mood. It is also the time when the urge to find an outlet hits hardest as I can’t process those heavy feelings on my own. So I decided to write my feelings down and then post on the social media to let the emotions spill out. No one knows me on social media, so I don’t really care if anyone finds what I wrote. I post whenever I need to, and delete whenever I want.
[P4, aged 26 years, Douban]

Here, privacy did not depend on literal confidentiality but on social distance from unknown others and control over the permanence of disclosure. P6 similarly emphasized the necessity of releasing negative affect without expecting positive feedback from others, as “they don’t have any eligibility to carry my sorrow, and I just post to let things out.”

Documenting and Making Sense of Personal Illness Journeys

Some participants used posting to preserve experiences they feared might later be forgotten or blurred. For example, P18 reported documenting her thoughts on counseling and clinical symptoms so that she could revisit them later.

P20 described how she documented her feelings before undergoing modified electroconvulsive therapy (MECT), which she had heard would affect her memory.

At the time, I was about to take MECT. I once read online that it might affect my memory, so I took some photos beforehand and posted on Douyin, saying that ‘Starting treatment soon. I’m afraid I’ll forget everyone.
[P20, aged 16 years, Douyin]

P20’s post marked a moment before an uncertain intervention and represented an attempt to preserve continuity with the people and experiences she feared she might no longer remember.

For other participants, documentation served a more reflective function. Documenting the journey with mental disorders enabled them to organize emotional experiences, identify possible triggers, and trace changes in their responses over time. P14 explained:

When I’m suffering from emotional struggles, my way of coping with them is to put them down in words, and figure out what triggered them and how I can change to improve. This has been my habit for a long time. Once I have worked through and documented the experience, I post it on social media so that I can keep it as a record.
[P14, aged 23 years, Rednote]

Across these accounts, documentation served more than archival purposes. For some, it preserved experiences feared to be lost, while for others, writing made fragmented emotions more intelligible. Therefore, social media simultaneously functioned as an external memory and a reflective record for constructing continuity and meaning across illness experiences.

Turning Lived Experience Into Mutual Support and a Sense of Value

For some participants, posting mental health–related content gradually evolved into a way of helping others. Having previously benefited from information or comfort received on social media, they also wanted to give back by drawing on their own experiences to provide practical guidance, encouragement, and companionship to people facing similar difficulties. In this way, content creation could transform their painful or stigmatized experiences into useful resources for others while bringing creators a sense of fulfillment and value that they might barely receive in the real world.

P1, a 26-year-old Rednote creator, described her experience of being helped and comforted by strangers on social media and explained that she therefore chose to do the same as much as she could with the information she had acquired:

At first, I was just expressing myself on social media, but later I began receiving a lot of warm comments and replies from fellow patients, and gradually I felt a sense of responsibility. I realized that maybe they also needed a blogger like me to share my experiences and be there for them. Given that, I would choose to reply to comments that have a positive impact on me. For example, when someone says my videos were healing, or when they tell me that they have overcome their own limitations, broken through past struggles, and become better. In those cases, I’m more than happy to respond and offer mutual encouragement.
[P1, aged 26 years, Rednote]

Apparently, repeated interaction could also change the social meaning of posting. What began as self-expression became a reciprocal practice in which having once received support created a sense of responsibility to offer it to others. Recognition that others had benefited from their posts allowed some participants to reinterpret stigmatized illness experiences as socially useful knowledge. P17, a Weibo creator, stated that she had become friends with a young person with depression whom she had initially supported through comments. They had been able to share their lives with each other since then. P20 also established a group chat in which people experiencing mental health issues could exchange information, discuss treatment experiences, and encourage one another. Content creation could therefore develop into a broader form of peer support.

Theme 2: Audience Feedback Reshapes Emotional Experience and Subsequent Creation

Overview

Once personal experiences were posted publicly, content creation no longer remained solely an individual act of expression. Participants commonly described audience responses, which could be supportive, absent, invalidating, or unexpectedly influential in shaping how they evaluated both themselves and their posts. Over repeated interactions, feedback also influenced what they chose to post, how often they posted, and how much they oriented subsequent content toward their audience. It should be noted that most participants in this study had relatively modest audiences, ranging from dozens to hundreds of followers, with only 1 substantially larger account. Hence, we did not observe a clearly distinct pattern of feedback in this single larger-account case, and the analysis primarily reflects peer-scale rather than large-influencer audience interactions.

Sensitive Content Disclosures Brought Unexpected Visibility and Peer Resonance

Participants perceived that posts about intense negative affect and sensitive experiences, such as conflict with health professionals or self-harm and suicide, often received more views, comments, and replies than other mental health–related posts. These posts could also attract people with similar experiences, whose empathetic responses eased their distress and strengthened their motivation to continue posting.

P1 described how posting about living with bipolar disorder unexpectedly connected her with a community of people who also faced similar challenges.

I was experiencing a really dark and depressive time then, so I just wanted to make a video to express what it was like living with bipolar disorder. I never expected that video to resonate with so many people, receiving a bunch of comments and likes. The next few posts also received encouraging responses, and it felt as if I had finally found my peers and community. This kind of support is something you will never find in the real world. I then realized that I could combine my creativity with my illness, which encouraged me to continue recording and making posts online.
[P1, aged 26 years, Rednote]

P1’s account shows that what began as an attempt to express a depressive experience was reshaped through audience response into a more relational form of creation. Recognition from people with similar experiences did not simply provide emotional comfort. Instead, it gave the post a social purpose and made continued creation appear worthwhile.

Participants also felt that visibility did not always reflect content quality but rather the sensitivity of the topic. P11 described a brief post about an upsetting hospitalization as her most widely viewed post, although it was “one of the worst works” in her opinion.

During this vacation, I was hospitalized due to an overdose. After I was discharged, I posted about my two days in the hospital, which said that I thought I was discriminated against by the doctors and then I was discharged against my will. The nurses were impolite to me, too. The post was a very short piece with just a few hundred words, but it ended up with over 10,000 views. A lot of people shared it, and it seemed to be recommended everywhere. I have no idea why it’s gotten so much attention because this is one of the worst things I’ve ever written. It’s not that high-quality. Maybe it’s the algorithm of the platform or this kind of content just tends to spark controversy.
[P11, age 21, Rednote]

This account suggests that unexpected reach also destabilized participants’ assumptions about what visibility represented. They could not clearly distinguish the effects of topic sensitivity, controversy, and algorithmic recommendation. Consequently, greater attention could provide recognition and belonging while also exposing creators to audiences and interactions they had not anticipated or controlled.

Supportive, Absent, and Invalidating Responses Produced Contrasting Emotional Consequences

Participants indicated that audience feedback was consequential because posts were often created during periods of heightened emotional vulnerability. The majority of responses were positive, which greatly alleviated distress by signaling that creators had been noticed and understood. In contrast, limited engagement, hostile comments, or responses that failed to acknowledge the complexity of mental illness could impose an additional emotional burden, including disappointment, self-doubt, guilt, and helplessness.

P5, a Rednote creator, described how different forms of feedback affected both her mood and her evaluation of her own content.

I usually post mental health–related content when I’m really down, and those warm comments have brought me a lot of comfort and helps ease my mind. At first, I was thinking that if I can have one or two followers who liked my content, that would be enough. But actually, I’ve now got a dozen of people who have been following and supporting me for a long time. However, (if my posts got few views or replies, I might feel sad. I wonder if Xiaohongshu had limited the recommendation of my post. If not, then it must be that what I wrote was not appealing. Why would it be like this? How can I improve? I’ll keep writing, but I’ll lower my expectations a bit.
[P5, aged 22 years, Rednote]

Feedback, therefore, could function simultaneously as emotional support and as an evaluation of the content. Because participants could not know whether low visibility reflected platform recommendation or a failure of their content to resonate, limited feedback could be internalized as a regression in creative capacity.

Negative and hostile comments could also leave participants feeling angry, hurt, or helpless. P11 stated that she felt misunderstood by strangers on social media.

I’ve got some really condescending comments from strangers, saying that ‘If you’re brave enough to die, why aren’t you brave enough to live?’ These comments hurt me too. Sometimes, people said nothing rude. They just tell me the usual lines, like, ‘Being alive is the most important thing, don’t go down that path’, or they would advise me to exercise more, or think me feeling this way because I have too much free time. It is difficult to argue with comments like these. I know that they may come from a place of concern, but they leave me feeling even more guilty and powerless.
[P11, aged 21 years, Rednote]

What mattered for participants was not whether a response was conventionally “positive” but whether it genuinely acknowledged their subjective experience. Empathetic responses could offer comfort and reassurance, while those perceived as dismissive or disconnected tended to reproduce the misunderstanding that had prompted participants to seek support online in the first place.

Feedback Reshaped Subsequent Content Creation and Interaction

Beyond the immediate emotional consequences, feedback also shaped participants’ willingness to continue creating content and the direction of their subsequent creation. Repeated questions, expressions of interest, and supportive responses could shift posting from personal documentation toward more audience-oriented content. Conversely, hostile or confrontational responses could reduce posting or narrow the topics participants considered safe to discuss.

P9 described how her motivation shifted from documenting her own treatment process to considering her followers’ expectations.

Most of the content I post was about my symptoms and experiences with manic, depressive, and mixed episodes. It was very personal and subjective. Many people commented below asking how to make an appointment with doctors, what medications I was taking, or whether their symptoms also indicated bipolar disorder. With more and more comments and messages, I’ve decided to share some of my experiences, perspectives, and thoughts. It’s kind of a shift from a passive to an active action. As I have got more followers, I want to retain as many of them as possible, if they still have interest in my content. So my posting frequency might change from once a week to several times a week.
[P9, aged 25 years, Rednote]

Audience engagement thus became an input into later production rather than simply a reaction to completed posts. Repeated questions and growing follower expectations shifted P9’s posting from personal documentation toward a more audience-conscious practice. P5 similarly compared the desire for further attention after receiving positive responses to “a peacock spreading its tail.” In contrast, P18’s withholding of posts after hostile responses shows the same feedback process operating in the opposite direction. Feedback therefore shaped both immediate emotion and the conditions of further creation.

Theme 3: Disclosing Mental Illness Experience Requires Emotional Effort and Boundary Management

Overview

Making personal mental health experiences visible required participants to manage multiple forms of vulnerability. Creating content could be emotionally demanding when participants were unwell or revisiting distressing experiences, while there was also uncertainty over who might see, interpret, or respond to these posts about their self-disclosures. Participants therefore continually negotiated what to reveal, which audiences to allow access to, and how to respond when visibility led to offline recognition, conflict, harassment, or unwanted contact.

Illness States Impeded the Creating Process and Imposed Additional Emotional Burdens

Participants described their ability to create mental health–related content as closely tied to their illness state. Memory difficulties, dissociative experiences, and severe low mood could make it harder to recall, organize, or present personal experiences, adding effort to a process that was already emotionally demanding.

P6 described how memory loss and dissociative states affected her when she tried to document her experience of mental disorders:

I feel like I’ve forgotten so many things over the years, especially the painful ones, since I was ill. I simply can’t remember them anymore. It was only later that I realized how serious my condition was. There is a term called dissociative amnesia. I cry a lot, but I don’t even remember what that emotion felt like. If you asked me to recall that pain, I could not. But creativity comes from pain. I have nothing to write about without those memories.
[P6, aged 26 years, Weibo]

Memory difficulties and dissociative experiences disrupted creators’ ability to construct a narrative about past distress. Conversely, when participants were able to retrieve and document distressing experiences, revisiting and representing them could be a second traumatizing experience.

P1 described attempting to film herself during a depressive episode:

Filming myself probably made my depression worse. I had to face the camera and record myself in that depressive state. I couldn’t just pretend that the lens was not there. I could not accept such a depressed me on camera.
[P1, aged 26 years, Rednote]

These accounts reveal a tension in creating from illness experience. When memories were inaccessible, participants lacked the material needed to narrate the past. Also, when distress could be retrieved, turning it into content could reactivate discomfort and require confrontation with versions of the self they found difficult to accept. Creating content could therefore become especially demanding when participants were already unwell.

Online Self-Disclosure Imposed Potential Risks of Unexpected Visibility and Offline Recognition

Some participants were unwilling to let family members and friends find their posts containing negative and sensitive content. They worried that posts created during a period of temporary emotional outburst might be interpreted as representing their entire identity or might create feelings of helplessness and worry in close relationships. To maintain separation between audiences, participants would choose anonymous or multiple accounts, block acquaintances, or delete accounts if they were recognized.

P10, a Rednote creator, described feeling alarmed when her social media account was discovered by people from her offline life:

Sometimes when I found someone I might know has liked or commented on my posts, I will start to panic, and then block them. Once, an acquaintance I’m not that close with in real life found my Xiaohongshu account and asked if it was me. I was so freaked out that I immediately deleted my account that night.
[P10, aged 17 years, Rednote]

If my parents or relatives find my account, I will never admit it. Because the content I post probably would not be easily understood by them. I don’t think it’s necessary to tell them about it. Although we would not argue a lot, we don’t really communicate that much either. So I feel like it would be really awkward if they saw things I wrote.
[P10, aged 17 years, Rednote]

Across these accounts, the perceived safety of online disclosure depended on separating online and offline audiences. Recognition by an acquaintance indicated access to a hidden version of themselves. Blocking users and deleting the account were therefore ways to restore boundaries after the anonymity of the space had been disrupted.

Other participants were concerned about spreading negative affect to others, especially being found by people close to them. P4 explained why she preferred to express distress on anonymous platforms rather than directly approaching family or friends:

My family and friends don’t know about my Douban or Weibo accounts. I post on anonymous social media platforms instead of telling them because mental health issues are not something they can help me with. I still need to see a doctor and take medication. When I attempted to talk to them about how I feel, they wanted to comfort me but do not know how. I can sense their helplessness, and that makes me feel a bit guilty, like I’m burdening them. Letting them know I’m not doing well, or expressing too much negativity to them, isn’t really a good idea.
[P4, aged 26 years, Douban]

P4’s account suggests that anonymous posting on social media allowed her to express distress without placing an additional emotional burden on close others or raising a problem that they were unable to address. Social media platforms therefore functioned to reduce anticipated awkwardness, helplessness, and guilt on both sides. Across these accounts, perceived privacy depended less on absolute anonymity than on control over audience boundaries. For P4, a pseudonymous account created distance from close offline relationships, while for P10, recognition by an acquaintance collapsed that separation. Visibility therefore depended not only on how many people could see a post but also on who those viewers were and whether participants had intended them to become part of the audience.

Controversial Content Might Provoke Skepticism, Arguments, and Harassing Messages

Because mental health experiences are personal and contested, public posts could attract responses that questioned the legitimacy of participants’ views or judged their decisions. In some cases, disagreement about an issue placed creators at the center of skepticism and conflict.

P9 described the response to a post about being registered for community-based management of severe mental disorders:

Many people are strongly opposed to having their diagnosis of bipolar disorder reported to the community, but I personally do not mind it, so my position was different from most people. Someone said that what I had done was inappropriate, or asked why I agreed to be followed up by the community worker. They picked apart the decisions I had made and judged them as wrong, without considering my perspective. Everyone has different views, but eventually my comment section became increasingly chaotic. It felt like a battlefield.
[P9, aged 25 years, Rednote]

This disagreement occurred within a specific institutional context. In China, bipolar disorder is one of 6 severe mental disorders included in the national Serious Mental Illness Management System, under which diagnosed individuals may be registered and receive community follow-up [26]. Concerns regarding privacy, the balance between treatment and control, and the consequences of registration have also been documented. The disagreement surrounding P9’s post therefore did not originate solely from attitudes toward her as an individual but reflected differing views toward participation in this management system. However, as the person publicly expressing a position on this contested issue, P9 became the focal point through which this broader disagreement was expressed, turning an institutional controversy into a personal burden of content creation. This underscores a specific challenge that mental health–related content creators may face.

The possibility of conflict also shaped how participants wrote before publishing. P3 described deliberately limiting vulnerable details and using cautious, relatively objective language because previous online disputes had developed into prolonged harassment:

I am quite cautious with my wording. I avoid posting controversial content that could later become a trigger of argument. I also try to remain objective and avoid revealing too much of my vulnerable side. I am afraid of online harassment, especially because I have posted a large amount of content online, disclosing many details about myself. I am open to disagreement, but it freaks me out when it grows on a large scale. I once had a conflict with someone who continued harassing me for several months, and his account was eventually suspended for a month after I reported it numerous times.
[P3, aged 23 years, Rednote]

Previous harassment shaped content before a post was published, leading participants to restrict vulnerable details, adopt more neutral language, or avoid certain topics altogether. Boundary management therefore extended across the entire posting process after feedback was received; participants deleted comments, blocked users, restricted commenting permissions, or withheld posts when interactions became confrontational.

Sensitive disclosures also attracted unwanted contact, including persistent promotion of self-help courses and offers of paid or free counseling from strangers claiming professional expertise. Such approaches blurred the boundary between support and commercial solicitation and could leave participants feeling frightened or pressured.

Discussion

Principal Findings

This RTA examined how young Chinese creators experiencing mental health challenges engaged in repeated mental health–related content creation on social media, from their motivations to the consequences of making personal illness visible through audience feedback.

A total of 20 women participated in the interviews. Although a formal psychiatric diagnosis was not an eligibility criterion, all participants subsequently self-reported a clinician-assigned mental health diagnosis or clinical label during the interviews. Therefore, the findings should be understood as reflecting the experiences of young content creators with self-reported mental health histories. Participants initially posted to seek recognition and support, express negative affect, document mental illness, and use lived experience to help peers facing similar challenges. Previous studies have found higher social media dependence among people with mood disorders due to a lack of offline support. Self-expression on social media has effectively reduced their loneliness and improved their psychological well-being [27]. In this study, participants described insufficient offline support as a lack of understanding of their mental health issues. Similar difficulties in relying on informal family support have been reported among people with depression both in China and worldwide; namely, limited understanding of mental illness, stigma, and family obligations can shape disclosure and support-seeking [5]. However, our participants primarily described misunderstanding, uncertainty about how family members could help, and concerns about burdening close others rather than explicit experiences of discrimination. This led to a perceived lack of offline support and made them eager to seek understanding and support from peers with similar experiences, while social media provided an accessible platform for this. Therefore, even a like or comment under their posts mattered less as advice than as evidence that their pain and distress had been noticed. This was consistent with research on self-harm image posts and severe mental illness vlogging, which found that belonging and peer recognition were prominent motives for content creators [13,28]. Hence, posts expressing negative moods generally offered a relatively private and controllable way to release emotions with fewer interpersonal demands.

Some participants described forgetting or difficulty organizing illness-related experiences, a phenomenon termed perceived cognitive deficits. These deficits included perceived problems with memory, attention, or organization, which are commonly reported by people with depression and have been associated with poorer psychosocial functioning and recovery-related outcomes [29]. Posting therefore also helped participants preserve and organize illness experiences, particularly those who had concerns about memory loss due to a particular treatment or medication [30]. Our findings showed that participants used posts as an external memory for experiences that felt difficult to retain and organize. Documentation helped them identify emotional triggers, trace changes over time, and impose coherence on fragmented experiences, which was also common among patients with other chronic diseases [31]. Similar processes have also been described in online depression recovery narratives [32].

Content creation could also transform the lived experience of creators into peer support. Consistent with previous research, participants who had previously benefited from informational and emotional support later used their own experiences to provide practical information, encouragement, or peer companionship as well [33]. Importantly, the gratitude from followers also brought a sense of value and responsibility, which greatly compensated them emotionally.

Audience feedback is also an important part of what shapes creators’ emotional experiences and subsequent content creation. Participants reported that posts about intense negative affect, self-harm, suicide, or conflict tended to draw more views and interactions involving comfort and resonance. Some of our participants also interpreted unexpected increases in visibility in relation to platform recommendation mechanisms or the sensitivity of the topic. This aligns with studies reporting higher engagement with suicide-related content on TikTok than with positive content [34], which accounted for approximately 45% of daily recommendations [35]. This study suggests that engagement with mental health–related content can increase subsequent exposure to similar material, while recommendation systems may have limited sensitivity to whether such engagement reflects transient distress, help-seeking, or sustained interest [35]. Similarly, our participants also reported being exposed to audiences and responses they had not anticipated. Therefore, platforms could provide creators with greater control over post visibility, commenting, direct messaging, and audience access, together with accessible tools for filtering, blocking, and reporting hostile or unwanted interactions to support a safer environment for mental health–related expression.

Nevertheless, sensitive posts often received supportive feedback that could meet creators’ expectations, which brought them a sense of contentment, hope, and meaning and therefore made them feel recognized and encouraged. This facilitated their mental health recovery [36] and also empowered them to continue posting. In contrast, hostile comments or disagreement could lead participants to post less, avoid discussing sensitive topics, or revise the wording to prevent conflicts. Specifically, for creators who posted repeatedly, each response could become part of the conditions under which the next post was planned, revised, or withheld, or under which creators shifted from personal expression to meeting audience interests, a process termed “audience entanglement” [37]. Also, engagement metrics, including the number of views, likes, and comments, functioned as both indicators of social recognition and evaluations of content quality [16]. Unsatisfactory feedback could cause an additional emotional burden, such as self-doubt and anxiety, for creators with mental disorders, resulting in worse mental health and a decline in subsequent motivation to create content [38].

This burden may extend beyond audience feedback. Memory deficits and dissociative states caused by mental illness limited the capacities needed to narrate participants’ experiences, while revisiting or filming periods of distress required them to confront versions of themselves they found difficult to accept. These findings are consistent with those of individuals with bipolar disorder [39]. Other studies suggest that documenting illness could preserve fragmented experiences and support meaning-making, but recalling, organizing, and publicly representing those experiences could reactivate distress [40]. In this way, content creation carried both expressive value and emotional costs. Another concern that participants reported was that their posts could be disclosed to family members or acquaintances in the real world, who might interpret a temporary expression as their complete identity because of a lack of understanding of mental health issues. Separate accounts, blocking, deletion, and cautious wording allowed them to seek recognition without fully merging online and offline audiences. Boundary work also extended to conflict and unwanted contact. Disagreement on controversial topics, including treatment or hospitalization, could shift into judgment of the creator and then lead to arguments, bringing extra pressure to creators. This content also attracted messages from strangers promoting courses or offering counseling, which further blurred the boundary between support, commercial use, and unwanted contact. These risks can narrow future expression and require ongoing defensive work. In their study, Andalibi and Forte [41] argued that social media platforms should provide privacy controls for both disclosers and responders, rather than treating all sensitive disclosure as content to be removed.

The coexistence of peer support and unwanted visibility also has implications for platform design. Our findings suggest that sensitive mental health disclosure should not simply be restricted, as these posts could provide recognition, belonging, and peer support for creators. Instead, platforms should provide creators with greater agency over audience boundaries through more granular controls over post visibility, commenting, direct messaging, and audience access, alongside accessible filtering, blocking, and reporting tools for hostile or unwanted interactions. Such controls may allow creators to maintain the benefits of wider peer connection while regaining control when visibility or interaction becomes unwanted. This approach is consistent with previous research on sensitive disclosure recommending stronger privacy controls for disclosers [41] and with recent evidence cautioning against blanket restrictions on self-harm–related content while emphasizing user-centered safety controls [42].

Apart from these considerations, gender should also be considered as part of the context in which these findings were produced. All participants were women, and most primarily used Rednote, a platform whose user base is predominantly female. This context may partly have contributed to the composition of the recruited sample. However, our participants did not consistently frame their experiences of disclosure, visibility, harassment, or boundary management in gendered terms. We therefore did not determine which patterns, if any, were specifically shaped by gender. Future studies including men and gender-diverse creators may clarify whether these experiences differ across genders.

Practical and Policy Implications

According to our findings, several practical and policy implications can be considered for different stakeholders.

First, social media platforms could provide granular control over post visibility, commenting, direct messaging, and audience access, together with accessible tools for filtering, blocking, and reporting harassment or unwanted contact to reduce unexpected visibility, boundary disruption, and harassment.

Second, family members and close supporters could provide nonjudgmental acknowledgment and emotional support without minimizing distress or immediately trying to resolve it, and could respect young people’s disclosure boundaries. This may reduce the misunderstandings and interpersonal burdens that led some participants to rely on anonymous or peer-based online support.

Third, clinicians and mental health care providers could consider patients’ social media activity, including frequency of use, content creation, online conflict, and unwanted exposure, as part of psychosocial assessment when relevant. This could help identify when online interaction functions as peer support and when it becomes an additional source of emotional distress.

Limitations

This study has several limitations. First, participants were recruited online through purposive sampling on social media, and participation required a willingness to discuss personal mental health and content-creation experiences. Because repeated content creation was operationalized as at least 5 original mental health–related posts within the previous 12 months, individuals who stopped posting after early negative experiences or deleted relevant posts or accounts may have been less likely to be recruited; experiences associated with rapid or permanent disengagement may therefore be underrepresented. Second, detailed audience composition was not systematically collected, limiting our ability to examine how different audience relationships shaped visibility and interaction. Third, participants’ clinical histories were self-reported and were not independently verified through medical records or structured diagnostic interviews, as a mental disorder diagnosis was not one of the inclusion criteria. This might limit the precision with which participants’ diagnostic characteristics can be described, although diagnosis was not used as the basis for the thematic analysis. Finally, interviews and analysis were conducted in Chinese, and quotations were translated into English; some culture-specific meanings may not be fully transferred to other settings. However, our findings focused on common issues related to mental health and social media use among youth worldwide; they could still provide insightful evidence for broader digital-native populations, with interpretation remaining sensitive to local cultural and platform differences.

Conclusions

Young creators repeatedly created mental health–related content to express emotions, seek recognition, document illness experiences, and support peers. Audience feedback influenced both emotional responses and subsequent content creation, while making mental illness visible required emotional effort and exposed creators to unwanted recognition, conflict, and harassment. These findings highlight the coexistence of supportive and potentially burdensome experiences in repeated mental health disclosure on social media.