Sexual and gender minority (SGM; ie, lesbian, gay, bisexual, transgender, and otherwise queer [LGBTQ+]) young adults experience well-documented disparities in both internalizing [1,2] and externalizing psychopathology [3] compared with their cisgender heterosexual peers. These mental health disparities persist into adulthood and are present even among SGM people who identify as such late in their adolescence or young adulthood [4]. Minority stress theory [5] poses that, given the dominant culture, norms, and social structure, SGM people are likely subjects of an incongruence between information provided by society on how the world works and the minority person’s experience of the world, determining stress processes that may worsen depression. Minority stress is the prevalent framework used to explain disparities seen in depression among SGM people; expansions of it have been developed for specific conditions such as substance use [6], cardiovascular disease [7], suicidal thoughts and behavior [1] and certain SGM groups such as adolescents [8,9] and transgender persons [10-13].

Social media encompasses a variety of websites and mobile apps (eg, TikTok, Snapchat, and WhatsApp) that enable users to create and share content and participate in web-based social networking [14]. Over 90% of adults in the United States have at least one social media account, which they use for an average of 2 to 4 hours daily, with YouTube, Facebook, and Instagram among the most popular platforms, and people aged 18 to 30 years being the group with the most sustained use growth among adults [15]. In addition, the affordances of social media (eg, asynchronicity, absence of physical cues, permanence of interactions, quantifiability via likes, and upvotes) have deeply changed the way in which people socialize, connect with others, build relationships, and seek and receive support and information [16,17].

On average, SGM people are more socially active on social media and more likely to have multiple social media accounts than non-SGM individuals [18-20]. Moreover, SGM persons seek and engage with more web-based support chats than their non-SGM peers [21]; seek web-based support resources to help them navigate challenging settings where both racial and sexual minority stigma might be salient [22,23]; and use social media to connect with others like them, increase their sense of belonging, and increase emotional well-being [24]. Despite these positive experiences, negative social media interactions also give way to social comparison, stigmatization, cybervictimization, and other forms of discrimination, which in turn might influence depressive symptoms [25,26] and other psychopathology [27,28].

Although there is qualitative evidence available from SGM people indicating the salience of social media interactions to them [23,26], few studies have been conducted to determine the impact of social media interactions on mental health outcomes among SGM individuals, mostly among college students [29]. Moreover, the available studies follow the recent literature trend of focusing on determining the effect of the amount of time spent on social media (eg, time elapsed while using social media, number of checks per unit of time, and number of platforms used) on mental health. In the general population, the former approach showed mixed findings of positive [30,31], bidirectional [32], or no association [33] between quantity of social media use and mental health outcomes over time. These conflicting findings are indicators that we need a new approach that focuses on studying the factors that matter to SGM social media users, including the types of interactions and behaviors on social media platforms and their impacts on mental health. This is relevant as it is during these experiences on social media that SGM persons might encounter some of the minority stressors or protective factors [5,8]. On the basis of minority stress and our preliminary work [25], we propose a mediation model (Figure 1) in which the relationship between specific social media interactions and behaviors and depressive symptoms is mediated by both protective and risk factors (eg, emotional support experienced on social media). An additional issue that arises is that quantitative results alone are inadequate to describe and fully explain SGM young adults’ social media behaviors and interactions or their effect on their mental health. Therefore, a mixed methods approach has the potential to unveil stressors and protective factors uniquely shaped by the affordances of social media, which may influence mental health outcomes in ways that could be different from similar offline interactions and behaviors.

The PRIDE iM study will be the first longitudinal, mixed methods research conducted to determine the impact of several forms of social media interaction and behavior on the pathways of depression and other mental health outcomes among SGM young adults living in the United States (Multimedia Appendix 1). To address critical methodological factors needed to ensure a high-quality longitudinal study with SGM people, the main characteristics of PRIDE iM include (1) recruitment via social media to reach members of an often-marginalized group who are users of the technology under study, (2) recruitment of young adults aged 18 to 30 years as this age group recently experienced the most sustained growth in social media users, (3) presurvey qualitative assessments to identify relevant SGM-specific social media interactions and behaviors and add them to the survey, (4) repeated measures of potentially critical risk and protective interactions and behaviors on and off social media, (5) postsurvey qualitative assessments with survey participants to contextualize the trajectory of depressive symptoms, and (6) a mixing analysis phase to identify similarities and differences across groups. Upon completion, the PRIDE iM study will provide critical data in terms of intervention targets, such as reducing the occurrence or impact of risk factors (eg, upward social comparison) or boosting protective factors (eg, social connectedness) for depression and other negative mental health outcomes among SGM people—a high-need, underserved, and hardly reached population.

Given the longitudinal nature of our study, we leveraged a multistage mixed methods framework in which we combined both exploratory and explanatory approaches [34]. PRIDE iM uses a bookends variation of the longitudinal sequential mixed methods design [35], which is a combination of prospective and retrospective studies. In this design, we gather qualitative data in the form of individual interviews at both the beginning (T1) and the end (T6) of the study and collect quantitative data in the form of 4 longitudinal web-based surveys (T2, T3, T4, and T5) at nonconcurring times with the collection of qualitative data. Figure 2 provides an overview of the study design, including timing of data points for both quantitative and qualitative data strains as well as for analyses, data mixing, and interpretation of results. Throughout this paper, we use T1 to T6 to designate each point of data collection.

The design that we chose was appropriate for 3 reasons. First, we used a qualitative phase (T1) comprising web-based individual interviews to inform the building and content of the quantitative survey. Although the existing literature provided a list of potentially relevant risk and protective forms of social media interactions and behaviors for depression among the general population [36,37], we focused on social media experiences involving minority stress that are unique to SGM persons and that might help explain depressive symptoms among this group. We decided to conduct individual interviews, and this was appropriate to balance a need for an in-depth understanding of the impact of social media experiences on mental health with the need to protect individuals’ privacy and sensitive information. Second, we used a longitudinal web-based survey study with 4 data points (T2-T5), each one collected every 6 to 8 weeks. We sought to capture change in the association between the main predictors (ie, social media interactions and behaviors) and outcome variables (ie, depressive symptoms) over time. Using these 4 data points, our analyses will be able to identify trajectories of depressive symptoms over time. Third, given the limitation of quantitative data to fully explain the change in social phenomena over time, we will conduct a second qualitative phase of web-based interviews (T6). We will use the outcome trajectories identified in the T2 to T5 quantitative analyses and form groups based on these trajectories for conducting web-based interviews with SGM persons who participated in the survey in each of these groups. We will use the interviews to contextualize trajectories found in survey analyses and then conduct a comparative analysis of qualitative findings by groups identified in the survey (eg, respondents with severe vs mild depressive symptoms) to describe similarities and differences between said groups.

All recruitment and data collection procedures were approved by the University of Pittsburgh Institutional Review Board (study 19050007; approval June 20, 2019). We sought and obtained informed consent from potential participants before completing any of the research activities (web-based interviews or web-based surveys) of the study. Given that PRIDE iM study participants can be located anywhere in the United States and as the study posed minimal risk for participants, we obtained a waiver for documenting consent. We included all the standard components in the web-based informed consent forms, including study goals and description and estimated time required to complete the activity. Participants receive web-based gift cards in compensation for their time taking part in each of the research activities. We collected no identifiable information other than participant email addresses, phone numbers, and IP addresses (which were collected automatically by the web-based survey platform). This was necessary to schedule participation in the web-based interviews and to send gift cards to the participants after completing a research activity. Given the inclusion of sensitive topics and questions in both the interview and survey, we inform participants that they can choose to stop taking part at any time if they feel uncomfortable. In the web-based surveys, if the participant answers affirmatively to any of the suicide-related questions, a pop-up screen appears where we provide the contact information of nationally available resources for both SGM people and persons with suicidal ideation. These same resources appear listed at the end of the survey, and we provide the name and contact information of the principal investigator for more personalized resources.

To our knowledge, PRIDE iM is the first national mixed methods study with a longitudinal quantitative phase (T2-T5) conducted in the United States to determine the relationship between a variety of social media interactions and behaviors and depression and other mental health problems that overburden SGM young adults. Moreover, our study is the first to adapt the minority stress model to explain the path by which social media interactions and behaviors may affect depressive symptoms among SGM young adults. Since the time when minority stress theory was initially developed [5], social media has disrupted most societal processes, from the way young adults make friends to the way they keep themselves informed and become involved with their communities, and this seems to be even more true for minoritized groups. The proposed study is appropriate, timely, and innovative in several aspects, from the social media–based recruitment (which allows for the participation of SGM persons who may not interface with offline recruitment venues and, thus, may be less likely to participate in research) to the study and survey design. Our study will dramatically expand on previous research [26] that focused on identifying that social media and other communication technologies influence resilience and coping among SGM youth. PRIDE iM results will provide important information about the impact of social media on mental health for researchers that seek to better understand health inequities among persons who are minoritized because of their sexual orientation, gender identity, and race or ethnicity and reduce those inequities via interventions.

This study has limitations to consider. First, our recruitment through social media (ie, Instagram and Facebook) might represent a barrier to participation for SGM young adults who do not use these specific platforms. However, this is unlikely given that a large majority of young adults who use social media have an Instagram or Facebook account [15]. Second, our surveys assessed social media interactions and behaviors via self-report, which subjects these reports to recall bias related to experiences on social media. To reduce this, surveys were collected every 6 to 8 weeks, and all measures asked participants only about their social media experiences “over the last 30 days.” Nevertheless, future studies would benefit from more objective methods for collecting social media data related to individuals’ interactions and behaviors. Third, we used survey assessments that are quite comprehensive, which might discourage some participants from responding to all survey items or cause them to do so hastily. To remedy this, we implemented several forms of participant engagement (eg, progressively increasing incentives, building a community around the study, and survey reminders) and data quality checks (eg, survey completion time, attention-control questions, and survey completion progress).

PRIDE iM builds upon minority stress theory, a foundational model used to understand mental health disparities among minoritized groups, and will contribute to our current understanding of how sociocultural factors influence SGM individuals’ depression outcomes in a new media environment such as social media. Our study will confirm, reject, or uncover the presence of potential relationships between social media interactions and behaviors and depressive symptoms as well as temporality and direction. We will disseminate our findings via relevant academic journals and infographics on the PRIDE iM social media presence on Instagram, Twitter, and Facebook. This study will provide fundamental groundwork to develop social media–based interventions that target modifiable interactions and behaviors that are most likely to influence mental health outcomes, thus seizing the opportunity to merge the popularity of this medium among SGM people with an evidence-based approach.