Images of Mental Illness in the Media - Schizophrenia Bulletin

Images of Mental Illness in the Media:Identifying Gaps in the Research

by Patricia A. Stout, Jorge ViUegas, and Nancy A. Jennings

AbstractThis article summarizes research published over thepast decade and identifies areas where future researchis needed to increase our knowledge of the media's rolein fostering or reducing mental illness stigma. The fol-lowing questions are addressed: (1) How is mental ill-ness portrayed by the media? (2) How do mediaimages of mental illness impact individuals' knowl-edge, beliefs, attitudes, and behaviors with regard tomental illness? (3) How can the media be used toreduce mental illness stigma? The review reveals alack of recent research on the U.S. media and a needfor precision in how mental illness and the media aredefined for study. Research is needed that involves abroader range of media channels as well as more dis-tinctions among different types of content within chan-nels and a more detailed analysis of media imagesthemselves. The largest gap to be addressed is the linkbetween exposure to media images and mental illnessstigma. Use of the media as a tool for change requiresa better understanding of what messages are con-veyed, how they are developed, and what role mediacontent producers play in creating these messages.

Keywords: Mental illness, media, stigma, televi-sion, newspapers, magazines, film.

Schizophrenia Bulletin, 30(3):543-561, 2004.

Mental illness is one of the most stigmatized conditions inour society (Tringo 1970; Albrechet al. 1982; Corriganand Penn 1999). People with mental illness experience allof the key features of the stigma process: they are offi-cially tagged and labeled, set apart, connected to undesir-able characteristics, and broadly discriminated against asa result (Link et al. 1989; Corrigan and Penn 1999; Linkand Phelan 1999). Several sources of negative attitudestoward people with mental illness include labels; behav-iors; attributions; misinformation, particularly regardingthe association between violence and mental illness (Linkand Phelan 1999); and lack of contact (Corrigan and Penn

1999; Corrigan 2000). A central aspect of stigma for peo-ple with mental illness is the perception that they are dan-gerous and unpredictable (Nunnally 1961; Link andCuUen 1986; Link et al. 1999).

The Surgeon General's first comprehensive report onmental health in 1999 identified the stigma and discrimi-nation associated with mental illness as major barriersdeterring people with mental illness from acknowledgingtheir mental health problems and seeking treatment (U.S.Department of Health and Human Services 1999). Manycontend that stigma is a major reason why one-fourth ofthe estimated 50 million Americans experiencing mentalillness yearly will not seek mental health services (Brownand Bradley 2002). The Surgeon General's report wasintended to help reduce such stigma and discrimination byproviding accurate information about mental illness andits treatment, and by encouraging the development andevaluation of fresh approaches to the reduction of stigma.

The mass media, including television and broadcastnews, are the primary source of information about mentalillness for many Americans (Yankelovich 1990). Themedia are believed to play a major role in contributing tomental illness stigma via the images they portray of char-acters with mental illness as well as the misinformationcommunicated, inaccurate use of psychiatric terms, andunfavorable stereotypes of people with mental illness(Wahl 1995). However, little is known about the media'srole in perpetuating or reducing mental illness stigma.

It has been nearly a decade since Wahl's (1992) sys-tematic review of more than 40 years of publishedresearch on images of mental illness in the media. Hereviewed research across a range of media channels,including television, movies, and popular magazines.More recent reviews of images of mental illness in themedia tend to focus on a specific media channel, such astelevision (Signorielli 1998), or on media consumed by a

Send reprint requests to Dr. P.A. Stout, Department of Advertising,University of Texas at Austin, 1 University Station A1200, Austin, TX78712; e-mail: [email protected].

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Schizophrenia Bulletin, Vol. 30, No. 3, 2004 P.A. Stout et al.

specific audience, such as children (WahJ 2003). This arti-cle summarizes research published since Ward's (1992)review, with the intent of identifying areas where futureresearch is needed to increase our knowledge of the roleof the media in fostering or reducing mental illnessstigma. The following questions are addressed: (1) How ismental illness portrayed by the media? (2) How do mediaimages of mental illness impact individuals' knowledge,beliefs, attitudes, and behaviors with regard to mental ill-ness? (3) How can the media be used to reduce mental ill-ness stigma? Gaps in previous research are identified anddirections for future research are suggested.

Why the Media May Matter

The study of media treatments of persons with mental ill-ness dates back to the 1950s (Taylor 1957; Gerbner 1959),with emphasis on the entertainment media's influences onthe individual. While television has been recognized ashaving a pivotal role in "socializing individuals and stabi-lizing lifestyles" (Gerbner et al. 1982, p. 291), individualsobtain health information from many sources (Neuendorf1990). Neuendorf includes entertainment media, and newsand documentary media, in addition to health profession-als and health professional organizations, and other indi-viduals as either direct or indirect influences on individu-als' health information and health images. Although themedia are but one source of the messages, it is generallythought that mass media images of mental illness perpetu-ate mental illness stigma.

Attempting to understand the influence of massmedia on individuals' attitudes and behaviors has been amajor focus of mass communication research. Two masscommunication theories, cultivation theory and sociallearning theory, are particularly helpful to understandinghow the media act as a socializing agent and thus mayinfluence the construction and perpetuation of mental ill-ness stigma.

Cultivation theory suggests that heavy exposure toconsistent and recurrent messages on television will "reit-erate, confirm, and nourish" values and shape perceptionsof social reality to conform to those presented on televi-sion (Gerbner et al. 2002, p. 49). According to cultivationtheory, Gerbner and his colleagues submit that "those whospend more time 'living' in the world of television aremore likely to see the 'real world' in terms of the images,values, portrayals, and ideologies that emerge through thelens of television" (Gerbner et al. 2002, p. 47). That is,people who watch a lot of television are more likely toexpress opinions and hold values similar to those repre-sented on television than are people who watch only a lit-tle television. For example, years of message analysesindicate that violent crimes occur more frequently on tele-

vision than they do in the real world, according to FBIstatistics; heavy exposure to television cultivates a mis-conception about crime and law enforcement in general(Gerbner et al. 2002). Applying this theory to mental ill-ness stigma would suggest that people who watch a lot oftelevision would assume a television world view of men-tal illness.

Similarly, according to social learning theory(Bandura 1986), learning can be achieved through notonly direct experience but also through observation.Individuals can learn a great deal about the worldthrough what they see and hear, particularly throughmedia sources (Bandura 2002). Bandura (2002) wouldsubmit that as people watch television they acquireknowledge about behaviors as well as social conven-tions such as rules of conduct. Furthermore, accordingto social learning theory, those behaviors that arerewarded are more likely to be learned and invoked thanthose behaviors that are punished or unrewarded. Onceagain, the nature of the depiction has implications forthe lessons learned. Applying this theory to mental ill-ness stigma would suggest that television teaches socialconventions of how to treat individuals with mental ill-ness.

Together, these two theories work in tandem witheach other; cultivation analysis provides descriptions ofthe recurrent messages that are being vicariously learnedvia observation (social learning theory). In the absenceof real world experience with people with mental illness,individuals may rely on the media for their perceptionsof those who have mental illnesses (Link and Cullen1986). Meanwhile, the media tend to consistently linkportrayals of people with mental illness and violentbehavior to a degree greater than the real world associa-tion (Wahl 1992). This recurrent depiction can lead tolearning through media exposure that people with mentalillness are dangerous, are to be feared, and should beavoided. Recent research supports this notion, findingthat those who watch a lot of television hold more nega-tive views of individuals with mental illness than dothose who watch only a little (Granello and Pauley2000).

In an attempt to better understand how the mediaportray mental illness, what the impact of these mediaportrayals is, and how the media might be used to reducemental illness stigma, a review of published literature onthe media and mental illness was conducted.

Methodology

A series of steps were used to gather the articles assessedin this article. First, keywords were used to search com-prehensive data bases, including EBSCO, MEDLINE,

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PsychlNFO, and PsychNET, to identify manuscripts pub-lished between 1990 and 2003. Keywords included suchitems as mental illness, psychiatric problems, mentalhealth, media, television, newspaper, film, magazines,Internet, World Wide Web, stigma, and prejudice. Theyear 1990 was chosen as the date to begin the search toprovide some overlap with papers either in press at thetime of or published concurrently with Wahl's review(1992). Second, the abstracts of the papers obtainedfrom this search were analyzed and selected accordingto criteria that evaluated the presence or absence of anempirical study (i.e., experiment, survey, interviews,content analysis, discourse analysis, and other qualita-tive techniques) and the nature of the article. Morespecifically, the references obtained via the keywordsearch that presented news items or editorials wereeliminated, as were articles in languages other thanEnglish. Last, the articles selected were examined andrelevant papers that were cited in the articles selectedvia the data base search (but that did not appear in thedata base) were included in the review, resulting in atotal of 34 qualified references. Table 1 presents the listof empirical studies examining media, stigma, and men-tal illness published between 1990 and 2003. Whileadditional articles were identified in the search (e.g., lit-erature reviews), only references reporting on newempirical research studies are included in table 1.

The method of analysis of the final set of articleswas a literature review. Although some argue for theapplication of meta-analytic techniques rather than tra-ditional literary reviews (Wolf 1986; Beaman 1991), itwas felt that the literature in the area of mental illnessstigma and mass media is insufficient to allow a mean-ingful application of meta-analysis. Echoing Wahl's(1992) findings, our search since 1990 found that thenumber of empirical papers that can be compared is rel-atively small because of inconsistencies between defini-tions of mental illness and methodological procedures.Because the main objective of this article was to pro-vide a panoramic view of what is known and whatremains unknown about the role of media images ofmental illness and stigma, it was felt that a literaturereview would be the most appropriate technique. Whilethis review was intended to be a comprehensive reviewof empirical research published on the topic since 1990,it is not exhaustive because it is biased in favor ofempirical studies. Some detail is provided about each ofthe studies presented, within the limits of space con-straints. Finally, while the intent of this article is to pre-sent new literature published since Wahl (1992), refer-ences to older and/or previously reviewed research aresometimes included to provide a benchmark for inter-preting current knowledge.

What Is Mental Illness in MediaContent Research?

Content analysis is the preferred method for assessing theprevalence of specific types of content in the media and isa useful tool for message evaluation (Krippendorff 1980;Neuendorf 2002). The method involves the use of formal-ized procedures to enable subsequent inference and analy-sis of media content and comparison of results of differentanalyses over time (Krippendorff 1980). In the case ofimages of mental illness in the media, this would includehow mental illness is defined when applied to charactersand references to mental illness.

The 1996 General Social Survey research indicatesthat the perception of what constitutes a mental illness haschanged in the public mind over time to include disorderssuch as depression and anxiety (Phelan and Link 1998;Phelan et al. 2000). While it is beyond the scope of thisarticle to debate the appropriate definition of mental ill-ness for use in media research and elsewhere, in recentstudies examining media content, mental illness tendedmore often to be considered generically (often as beingsynonymous with psychosis) (table 1). Only a handful ofstudies identified a specific diagnosis, such as schizophre-nia (Wahl et al. 1995) or obsessive-compulsive disorder(Wahl 2000). And, while some studies instructed mediacontent coders to identify the presence of mental illnessbased on categories in DSM-IV (APA 2000) (e.g.,Diefenbach 1997), others relied on specific labeling byother characters in the program to establish whether acharacter has a mental illness (Wilson et al. 1999*, 2000).

Given the relatively limited number of studies forreview and the tendency to define mental illness moregenerically in the literature, for purposes of discussion inthis article we do not distinguish among different types ofmental illness but frame the majority of our discussionaround mental illness as generally defined.

Representation of Mental Illness in theMedia

Previous Literature Revisions. It has been just over adecade since Wahl (1992) reviewed published researchfrom the 1950s through 1991 that addressed the fre-quency, accuracy, and impact of the mass media's por-trayal of mental illness (p. 343). He reported that depic-tions of mental illness occur across several mediaplatforms, including film (6%), television (10-20% ofprime-time programs), and popular magazines (Wahl1992). Furthermore, Wahl (1992) found a fairly consistentimage of mental illness in the media. Specifically, themedia tended to present severe, psychotic disorders

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Tabl

e 1

. Em

pir

ical

stu

die

s ex

amin

ing

med

ia, s

tig

ma,

an

d m

enta

l ill

nes

s, 1

990-

2003

Au

tho

rsP

ub

licat

ion

Ty

pe o

fye

ar

men

tal

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ess

Pu

rpo

seC

ou

ntr

y P

rim

ary

stu

die

d

met

ho

dM

edia

so

urc

e D

escr

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on

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esti

on

1i i 5' o

Alle

n an

d N

airn

19

97

Gen

eral

Des

crip

tion

of m

ass

New

Zea

land

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urse

med

ia c

onte

nt

anal

ysis

Ang

erm

eyer

and

19

96

Sch

izop

hren

ia

Mas

s m

edia

effe

cts

Ger

man

y S

urve

yM

atsc

hing

er

Ang

erm

eyer

and

20

01S

chul

zeG

ener

alD

escr

iptio

n of

mas

s G

erm

any

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tent

med

ia c

onte

nt

anal

ysis

Bis

chof

f an

dR

eite

r19

99G

ener

al

Cov

erda

le e

t a

l. 20

02

Gen

eral

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crip

tion

of m

ass

Uni

ted

Sta

tes

Con

tent

med

ia c

onte

nt

anal

ysis

Des

crip

tion

of m

ass

New

Zea

land

C

onte

ntm

edia

con

tent

an

alys

is

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kers

on e

t al

. 20

02

Sch

izop

hren

ia

Mas

s m

edia

effe

cts

Uni

ted

Sta

tes

Sur

vey

Die

fenb

ach

1997

G

ener

al

Des

crip

tion

of m

ass

Uni

ted

Sta

tes

Con

tent

med

ia c

onte

nt

anal

ysis

Prin

t m

edia

Mas

s m

edia

2

New

spap

ers

Film

New

spap

ers

Mas

s m

edia

Tel

evis

ion

Med

ia p

ract

ices

influ

ence

1

the

read

ers'

form

atio

n of

men

tal i

llnes

s m

eani

ngs.

Sub

ject

s' d

esire

for

soc

ial

2di

stan

ce i

ncre

ased

fol

low

ing

the

atta

cks

on 2

pro

min

ent

polit

icia

ns b

y in

divi

dual

s w

ithsc

hizo

phre

nia.

New

spap

ers'

em

phas

is o

n 1

the

cove

rage

of

men

tal

illne

ss e

licite

d by

bad/

sens

atio

nal

even

tsle

ads

to a

nov

erre

pres

enta

tion

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e st

orie

s.

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ale

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apis

ts w

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sexu

aliz

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eth

erap

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yed

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nt.

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gero

usne

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imin

ality

wer

e m

ore

freq

uent

the

mes

tha

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hum

an r

ight

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hmen

ts.

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0%

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part

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avin

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equ

ality

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ovember 2018

Pu

blic

atio

n

Type

of

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tho

rs

year

m

enta

l ill

nes

s P

urp

ose

Co

un

try

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mar

yst

ud

ied

m

eth

od

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ia s

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crip

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I 3 8.

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bard

and

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bard

Gra

nello

and

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ley

Gra

nello

et a

l.

Grie

rson

and

Sco

tt

1992

G

ener

al

2000

G

ener

al

1999

1995

Gen

eral

Gen

eral

Des

crip

tion

of m

ass

Uni

ted

Sta

tes

Con

tent

med

ia c

onte

nt

anal

ysis

Mas

s m

edia

effe

cts

Uni

ted

Sta

tes

Sur

vey

Mas

s m

edia

effe

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ted

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tes

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vey

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tude

s to

war

d U

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ym

enta

l illn

ess

Film

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and

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nsen

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y an

dH

owel

ls

2000

1995

Dep

ress

ion

Des

crip

tion

of m

ass

Uni

ted

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tes

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tent

med

ia c

onte

nt

anal

ysis

Sch

izop

hren

ia

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tude

s to

war

d U

nite

d S

urve

ym

enta

l illn

ess

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gdom

Lope

z19

91G

ener

al

Atti

tude

s to

war

d U

nite

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tate

s S

urve

ym

enta

l ill

ness

10 c

inem

atic

ste

reot

ypes

of

psyc

hiat

rists

and

thei

ref

fect

s ar

e pr

esen

ted.

1

Tel

evis

ion

Ele

ctro

nic

med

ia

New

spap

ers

Am

ount

of t

elev

isio

n vi

ewin

gw

as a

ssoc

iate

d w

ithau

thor

itaria

n vi

ews

and

nega

tivel

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rrel

ated

tobe

nevo

lenc

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se o

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onic

med

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a s

ourc

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ated

toto

lera

nce.

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ly t

o2

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nsid

er i

ndiv

idua

ls w

ithm

enta

l illn

ess

dang

erou

san

d un

pred

icta

ble

than

are

mem

bers

of t

he g

ener

alpo

pula

tion,

but

edi

tors

are

also

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like

ly t

o hi

re th

em.

Web

site

s B

ette

r in

form

atio

n ab

out

depr

essi

on is

nee

ded

and

valid

indi

cato

rs o

f si

te q

ualit

yne

ed to

be

deve

lope

d.

Mas

s m

edia

P

erce

ptio

ns o

fun

pred

icta

bilit

y of

peo

ple

with

sch

izop

hren

ia w

ere

corr

elat

ed t

o th

e us

e of

fictio

nal t

elev

isio

n as

aso

urce

of

info

rmat

ion

abou

tm

enta

l illn

ess.

Mas

s m

edia

A

dole

scen

ts w

ere

less

acce

ptin

g of

int

imac

y w

ithpe

ople

with

men

tal i

llnes

s.M

ass

med

ia w

as p

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as o

ne o

f the

mos

t im

port

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of a

ttitu

des.

1,3

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ovember 2018

Tab

le 1

. Em

pir

ical

stu

die

s ex

amin

ing

med

ia, s

tig

ma,

an

d m

enta

l ill

nes

s, 1

990-

2003

—C

on

tin

ued

00

Au

tho

rs

Lyon

s an

dZ

ivia

ni

Nai

rn

Nai

rn e

t al.

Pen

n et

al.

Pu

blic

atio

nye

ar

1995

1999

2001

2003

Type

of

men

tal

Illn

ess

Gen

eral

Gen

eral

Gen

eral

Sch

izop

hren

ia

Pu

rpo

se

Mas

s m

edia

effe

cts

Des

crip

tion

of m

ass

med

ia c

onte

ntan

d pr

oduc

tion

proc

esse

s

Des

crip

tion

of m

ass

med

ia c

onte

nt(p

rodu

ctio

n of

med

ia)

Dev

elop

men

t of

inte

rven

tion

Co

un

try

stu

die

d

Uni

ted

Sta

tes

New

Zea

land

New

Zea

land

Uni

ted

Sta

tes

Pri

mar

ym

eth

od

Inte

rvie

ws

Dis

cour

sean

alys

is

Dis

cour

sean

alys

is

Exp

erim

ent

Med

ia s

ou

rce

Mas

s m

edia

Prin

t m

edia

New

spap

ers

Tel

evis

ion

docu

men

tary

Des

crip

tio

n

Qu

esti

on

1

Occ

upat

iona

l th

erap

yst

uden

ts' a

nxie

ty t

owar

dw

orki

ng w

ith p

eopl

e w

ithm

enta

l illn

ess

(pro

voke

d in

part

by

mas

s m

edia

)di

min

ishe

d w

ith c

onta

ct.

The

pos

itive

dep

ictio

ns o

fm

enta

l illn

ess

prov

ided

by

psyc

hiat

rists

as

expe

rtso

urce

s w

ere

not

clea

rlyco

mm

unic

ated

bec

ause

of

jour

nalis

ts' n

eed

to c

reat

ene

wsw

orth

y na

rrat

ives

.

The

com

paris

on o

f a

com

mis

sion

er's

cas

e no

tew

ith t

he n

ewsp

aper

art

icle

sth

at c

over

ed th

e to

pic

indi

cate

d us

e of

ste

reot

ypes

.

Inte

rven

tion

had

a po

sitiv

eef

fect

on

attr

ibut

ion

of i

llnes

s

2 1,3

1 2,3

! 3nia Bulletin, Vol. 3 p

Phi

lo e

t al.

Red

a

Sha

in a

ndP

hilli

ps

1994

G

ener

al

Des

crip

tion

of

mas

s U

nite

d C

onte

ntm

edia

con

tent

K

ingd

om

anal

ysis

1996

G

ener

al

Atti

tude

s to

war

d U

nite

d S

urve

ym

enta

l illn

ess

Kin

gdom

1991

G

ener

al

Des

crip

tion

of m

ass

Uni

ted

Sta

tes

Con

tent

med

ia c

onte

nt

anal

ysis

but

caus

ed n

o ch

ange

s in

subj

ects

' atti

tude

s or

des

ireto

int

erac

t.

Mas

s m

edia

T

wo-

third

s of

500

new

site

ms

extr

acte

d fr

om U

.Km

edia

des

crib

ed a

link

betw

een

viol

ence

and

men

tal i

llnes

s.

Mas

s m

edia

E

xtre

mel

y ne

gativ

e at

titud

esto

war

d pe

rson

s w

ith m

enta

lill

ness

, atti

tude

s la

rgel

yfo

rmed

fro

m t

he m

edia

, w

ere

foun

d.

New

spap

ers

Crim

e st

orie

s re

late

d to

peop

le w

ith m

enta

l illn

ess

decr

ease

d in

the

span

of

the

stud

y, b

ut d

ange

rous

ness

of t

he m

enta

lly i

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(Nunnally 1961; Day and Page 1986). Persons with men-tal illness were depicted as being inadequate, unlikable,and dangerous (Signorielli 1989) and as lacking socialidentity (Wahl and Roth 1982). Characters with mental ill-ness were portrayed as unemployable—they were lesslikely to be employed outside the home and more likely tobe seen as failures when employed (Signorielli 1989).Even more consistent were depictions of violence anddangerousness associated with media images of mentalillness. Signorielli (1989) found that 72 percent of charac-ters with mental illness portrayed in prime-time televisiondramas were violent.

Wahl (1992) cited several limitations of the researchincluded in his review. First, the studies were old andmight not have reflected the changes that had occurred inthe industry, especially television, by the early 1990s.Second, methodological issues involving common ele-ments of content analysis such as a lack of consistency inwhat was being studied (e.g., a mental disorder and itstreatment vs. mental health treatment personnel and insti-tutions) and how to define and code relevant terms limiteddirect comparison of findings from the studies. Also, iden-tification of common characteristics of persons with men-tal illness varied based on the types of illnesses includedin the study as well as the nature of the sample (e.g., cod-ing actual media content vs. coding descriptions of filmand television programs).

Recent Research on Images of Mental Illness. SinceWahl (1992), the nature and scope of the study of mentalillness has changed. First, in Wahl's review (1992), televi-sion was "by far the most studied medium" (p. 344) andappeared to be the primary contributor of mental healthinformation. However, recent research on images of men-tal illness in the media indicates that while television con-tinues to receive a fair share of attention (Diefenbach1997; Wilson et al. 1999*, 2000), research attention toother media sources, including newspapers (Williams andTaylor 1995; Thornton and Wahl 1996; Allen and Nairn1997; Nairn et al. 2001; Coverdale et al. 2002; Wahl et al.2002), general circulation magazines (Wahl et al. 1995;Wahl 2000), and film (Gabbard and Gabbard 1992;Bischoff and Reiter 1999; Wahl et al. 2003), is growing.Some attention is being drawn to new media such as theInternet (Griffiths and Christensen 2000), yet no researchhas been conducted in the area of direct-to-consumer(DTC) advertising or public service announcements(PSAs). Second, of the few studies that examine televi-sion content, recent research not only assesses the mani-fest or surface content of mass media messages (mostoften using content analysis) (Diefenbach 1997) butattempts to identify the underlying meanings of messages(most often through discourse analysis) (Wilson et al.

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1999a, 1999b). Moreover, across all media outlets, a num-ber of studies have been examining print and visual contentoutside of the United States, most notably in New Zealand.

Over the past decade, research on media content hasindicated growing attention to images of mental illness inprint media, both in newspapers and in popular maga-zines. Previous research on newspapers indicates a linkbetween violence and mental illness. Shain and Phillips(1991) found that 85 percent of United Press Internationalstories reporting on former psychiatric patients empha-sized the perpetration of a violent crime. Philo (1998)suggests that this link between violence and mental illnessis amplified by U.K. newspapers' common practice ofnoting in the headline that a crime was perpetrated by aperson with mental illness. German newspapers alsoreport a disproportionate number of negative stories onmental illness linked to news coverage of sensationalevents (Angermeyer and Schulze 2001).

More recent research on newspapers includes trendanalyses that indicate that references to dangerousness aredecreasing in the articles that discuss mental illness (Wahlet al. 2002). In a national sample of 300 articles contain-ing the words "mental illness" from six U.S. newspapers,Wahl et al. (2002) found more coverage of issues ofstigma, fewer themes of dangerousness, and fewer articleswith a negative tone in 1999 than in 1989. Dangerousnesswas still the most common theme in 1999, however, andnegative articles outnumbered positive ones. Wahl andcolleagues also found that articles used the term "mentalillness" in lieu of naming a specific psychiatric disorder.Others have also found an increase in attention paid tocauses and treatments of mental illness (Shain andPhillips 1991) and an increase of references made tostigma and mental illness as well as more interest in pre-senting information about mental health policies and theirconsequences (Williams and Taylor 1995). However,images of mental illness associated with violence andunpredictability were also prevalent (Shain and Phillips1991; Williams and Taylor 1995).

Coverdale et al. (2002) examined 600 items depictingat least one person with mental illness published in anational sample of New Zealand newspapers over a 4-week period in 1997. News articles and editorial pieceswere most common (94%). Negative depictions occurredmost frequently, with dangerousness to others (62%) andcriminality (47%) the most common. Positive depictionsoccurred in 27 percent of the items and included themesof human rights, leadership, and educational accomplish-ments. Nearly half (47%) of the items used generic termi-nology for mental illness in lieu of a specific diagnosticcategory. While the authors caution that their findings donot generalize to media outside of New Zealand, theyconclude that print media portrayals of mental illness are

"negative, exaggerated and do not reflect the reality ofmost people with a mental illness" (p. 700). The authorsalso express concern that such depictions encouragestigma.

A few recent studies have examined how mental ill-ness, specifically diagnostic categories such as schizo-phrenia (Wahl et al. 1995) and obsessive-compulsive dis-order (OCD) (Wahl 2000), is presented in popularmagazines by assessing the type and accuracy of theinformation presented to the general public. Wahl et al.(1995) examined 137 magazine articles on schizophreniaidentified between 1964 and 1992 using the Readers'Guide to Periodical Literature. Few articles were found(nine annually), with the majority coming from "popularscience" magazines that reported briefly on specificresearch findings. Wahl (2000) conducted a similar exami-nation of OCD and identified 31 (of 107 total) articlesbetween 1983 and 1997 that discussed OCD explicitly. Heconcluded that these articles were fairly accurate in howthey presented symptoms, causes, and treatments. Theremaining articles identified focused on news-relatedissues involving obsessed fans stalking celebrities. Wahlcomments that this suggests a lack of distinction betweenOCD and "obsessive" behavior and may be communicat-ing misinformation.

Since Wahl's 1992 review, few studies have exam-ined images of mental illness on television. One study(Diefenbach 1997) content-analyzed a 2-week sample ofU.S. prime-time network television programming in thefall of 1994. In his sample of 184 programs, 32 percentcontained at least one character with mental illness. Thefocus of the study examined the relationship between theportrayal of persons with mental disorders and violentcrime. He found persons with mental illness to be nearly10 times more violent than the general population of tele-vision characters. The violent offender had a mental ill-ness in over 50 percent of the programs in crime dramas,reality-based shows, news magazines, and movies. Thisrate dropped to about 12 percent in other dramas, and nocharacters with mental illness were found in situationcomedies. In comparison with U.S. crime statistics, thepersons with mental illness portrayed on television were10 to 20 times more violent than those with mental illnessin the U.S. population.

Two studies that examined images of mental illnessin television were conducted in New Zealand. During1995-96, Wilson et al. (1999b) examined 14 prime-timetelevision dramas that included at least one character witha mental illness. Programs originated in the UnitedKingdom, Australia, or New Zealand (no U.S. programswere included in the analysis). Ten patterns or themeswere identified in the depiction of mental illness (includ-ing dangerous/aggressive, simple/childlike, unpredictable,

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failure-prone/unproductive, asocial, vulnerable, danger-ous/incompetent, untrustworthy, caring/empathic, andsocial outcast) that had different interplays in various set-tings and were shaped by the needs of the story within theprogram. Characters were depicted as physically violentand depicted negatively in the majority of occurrences.The authors found the portrayal of people who have amental illness "outstandingly negative" (p. 236) and con-cluded that this contributes to the stigmatization of thispopulation.

Similar results were found in a second New Zealandstudy (Wilson et al. 2000) that examined nearly 60 hoursof television programs directed to children under 10 yearsof age. Forty-six percent of the 128 episodes containedone or more references to mental illness, predominantly incartoons. Terms commonly occurring as referencesincluded "crazy," "mad," and "losing your mind" anddenoted loss of control. Characters with mental illnessportrayed in the programs were "stereotypically and bla-tantly negative and served as objects of amusement, deri-sion or fear" (p. 442). Yet the authors also found thatmany of the references to mental illness were about acharacter's actions in a situation rather than a character'snature or mental state (p. 441). The authors conclude thatyoung viewers are being socialized to have stigmatizingconceptions of mental illness.

In a recent review of a number of studies of thedepiction of mental illness in children's media in theUnited States, Wan! (2003) concluded that references tomental illness are frequent in these media vehicles gearedto children. The negative images that include links to vio-lence and criminality are more frequent than are positiveperspectives on characters who exhibit symptoms of men-tal illness.

Negative portrayals of characters with mental illnessalso appear in children's films. Wahl et al. (2003) exam-ined 49 children's films and found that 24 percent had atleast one character labeled as having mental illness and 43percent contained references to mental illness. Of the 14characters identified, the majority were adult, male, andCaucasian and were depicted as violent in 67 percent ofthe films. Wahl et al. found that mental illness tended tobe contextualized in a manner where other charactersresponded in positive ways to the character with mentalillness. Yet characters with mental illness also tended tothreaten and frighten other characters.

Not only are characters with mental illness portrayednegatively; two studies suggest that film also distorts theimage of mental health professionals. Bischoff and Reiter(1999) reported the results of a content analysis of moviesthat were shown in the United States between 1988 and1998 and included at least one character who was a men-tal health clinician. They identified 61 movies with a total

of 99 characters portrayed as clinicians. The authorsfound that female clinicians were more likely to be por-trayed as sexualized and male clinicians were more likelyto be portrayed as incompetent. Males were gender-stereotyped as ill-equipped to address the emotional prob-lems of others. The authors suggest that by understandingthe stereotypes of mental health professionals portrayed inmovies, therapists may be better able to address the mythsclients have about treatment.

Gabbard and Gabbard (1992) report on a criticalanalysis of nearly 85 years (1906-1989) of theatricallyreleased American movies, where roughly 300 films fea-ture a psychiatrist or other mental health professional.While they identify ten stereotypes found in cinema thatpresent psychiatrists in negative roles such as "libidinouslecher," "eccentric buffoon," and "unempathic coldfish,"positive stereotypes were also revealed. Like Bishoff andReiter (1999), they conclude that if therapists can under-stand the nature of the attitudes clients bring to counselingtreatment, this can enhance their understanding of theirclients' feelings.

Only limited research has been conducted focusingon new media such as the Internet or video games. ThePew Internet and American Life Project reports that theuse of the Internet as a source of information about healthissues in general is a normal activity for a majority ofU.S. Web surfers (63%) but not as preponderant for men-tal health issues (21%) (Fox and Fallows 2003). However,only a single study could be identified that addresses con-tent related to mental illness online. Griffiths andChristensen (2000) found that while the Web sites theyexamined contained useful information about depressiontreatments, the overall quality was poor because it wasdifficult to determine the scientific evidence behind theassertions found on these sites.

Finally, virtually nothing is known about how mentalillness may be represented to either perpetuate or reducestigma via messages delivered through DTC advertisingor PSAs. While PSAs have been used to endorse changein the stigmatization of people with mental illness(Epilepsy Foundation 2001; Brown and Bradley 2002),little is known about the effects of this type of message onthe public's knowledge, attitudes, and behaviors regardingmental illness, and no evidence has been collected to dateexploring the depiction of mental illness in PSAs or DTCadvertising.

Evidence of Effects of Mass Media andMental Illness Stigma

Correlational Evidence From Survey Research. Wahl(1992) concluded that research supported the belief that

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"media images of mental illness can influence publicknowledge and attitudes about mental illness" (p. 348).This conclusion tends to be echoed by other studies thatsuggest the mass media are an important source of infor-mation about mental illness and, in some cases, of nega-tive attitudes toward people who have a mental illness.Lopez (1991) examined the attitudes of adolescents aged14 to 18 about mental illness and found that mass mediaand parents are the most important sources of their atti-tudes on perceived personal experience with someonewith mental illness. Furthermore, Levey and Howells(1995) explored the beliefs about dangerousness, unpre-dictability, and differentness of individuals in relation topeople with schizophrenia and found that among mem-bers of the general public, and undergraduate college stu-dents in psychology and nursing, respondents believedthat people with schizophrenia are different from themand are unpredictable. They also found that higher ratingsof unpredictability were associated with participants'identification of fictional television as a source of infor-mation about schizophrenia. Moreover, these beliefs wereassociated with rejection and fear of people with mentalillness. Interviews with health care providers in the fieldindicated high levels of anxiety associated with personalcontact with a person with mental illness, attributed inpart to the mass media (Lyons and Ziviani 1995). Dailycontact lowered the negative feelings, however.

In an attempt to explore this relationship betweenmedia use and knowledge and attitudes about mental ill-ness, Granello et al. (1999) examined differences amongundergraduate students' scores on the CommunityAttitudes Toward the Mentally 111 (CAMI) (Taylor andDear 1981) questionnaire and their self-reported primarysource of information about mental illness. Individualswho reported receiving their information primarily fromelectronic media (e.g., television, film) reported less toler-ance of individuals with mental illness than did individu-als who received their information primarily from printmedia. In a subsequent study, Granello and Pauley (2000)examined the amount of television viewing by individualsand their attitudes toward persons with mental illness(Granello and Pauley 2000). Of 154 undergraduate col-lege students participating in the study, roughly one-third(53 students) reported that television was their primarysource of information on mental illness. Again, comparingscores on the CAMI as a measure of attitudes, amount oftime spent watching television was significantly and posi-tively related to intolerance toward mental illness, wasassociated with authoritarian views toward people withmental illness, and was associated with less positive atti-tudes of benevolence. The authors also found some evi-dence of differences in individuals' intolerance across dif-ferent genres of programs, with reported viewing of

daytime soap operas and prime-time situation comediesassociated with more intolerance. Overall, those whowatched more television had more negative attitudestoward persons with mental illness.

News coverage can also affect the perception of peo-ple with mental illness. Results of a longitudinal assess-ment of the general population's attitudes toward peoplewith mental illness after the reporting of attacks againsttwo German politicians by two individuals with schizo-phrenia (Angermeyer and Matschinger 1996) indicate thepublic's increased desire for social distance and a growingtendency to view psychiatric patients as dangerous andunpredictable. However, the conclusion of the long-termeffects of these reported crimes is unclear. Two years afterthe crimes took place, the desire for social distance waslower than immediately after the crime but still higherthan before the crime. Another longitudinal study in theUnited Kingdom (Reda 1996) assessed public perceptionsand attitudes toward persons with mental illness among100 residents of an urban area prior to and following theopening in their neighborhood of a residential facility forformer psychiatric patients. The interviews revealed nega-tive attitudes toward persons with mental illness, attrib-uted largely to how the media covered this event and theresidents of the facility.

Evidence From Experimental and Quasi-ExperimentalResearch. While these studies contribute to our under-standing of how the media may influence mental illnessstigma, survey research can provide only correlationalevidence for the impact of the media on knowledge, atti-tudes, and behaviors regarding mental illness.Experimental or quasi-experimental research can begin toprovide evidence about the link between exposure tomedia messages and mental illness stigma. Public educa-tion about mental illness is thought to be an importantway to affect stereotypes and stigma (Corrigan and Penn1999). It is assumed that more accurate information aboutmental illness will foster more positive attitudes towardpersons with mental illness. A handful of recent studieshave attempted to assess the impact of corrective informa-tion about mental illness by presenting different typesand/or formats of information via the media.

To examine whether negative news reports of violentcrimes by people with mental illness can be mitigated bycorrective information, Thornton and Wahl (1996) exam-ined the impact of four types of newspaper articles. Theattitudes of 120 college students were assessed using theCAMI measure as well as a set of fear and danger scales.Two types of corrective information were presented: oneaddressing and attempting to correct misconceptionsabout mental illness, and a second discussing media dis-tortion of mental illness. Participants who read the target

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article (compared to those who did not) were more likelyto indicate less acceptance of people with mental illnessand more likely to endorse statements indicating per-ceived danger from and fear of persons with mental ill-ness. However, the authors also found that participantswho read either of the forms of corrective informationprior to the target article reported more acceptance of per-sons with mental illness and less fear and perceived dan-ger than those reading the target article without the cor-rective information. The authors conclude that correctiveinformation may be effective in offsetting the effects ofnegative news reports about persons with mental illnessbut caution that generalization of the findings is limitedbecause of the absence of a preexposure measure of atti-tudes.

However, corrective information provided to viewersof a televised film was not sufficient to counteract thestigmatizing impact of the film (Wahl and Lefkowits1989). Wahl and Lefkowits (1989) attempted to reducethe negative effect on attitudes of a film depicting a killerwho had a mental illness with a film trailer that explainedthe nonviolent nature of mental illness. The trailer,intended to reduce participants' fear of violence in mentalillness, was shown on screen and read aloud, and pre-sented at three points during the film (at the beginning,after the first commercial, and at the end of the film).Eighty-six college students were shown a film with andwithout the film trailer. A third group of 19 studentsviewed a film not about mental illness. Attitudes wereassessed using CAMI measures after the film had beenviewed. Findings indicate that those seeing the target filmhad significantly less favorable attitudes toward mentalillness and community care than participants seeing thecontrol film, regardless of whether they viewed a trailerwith the target film. The information trailer did not miti-gate the negative influence of the target film on partici-pants' attitudes. The authors again point out the limits ofgeneralizability of the findings given the lack of a preex-posure measure of attitudes as well as the use of studentsin lieu of a sample more representative of the general pop-ulation.

Other researchers, such as Penn et al. (2003) andWalker and Read (2002), also found that cognitive mea-sures, such as attribution or causal explanations of mentalillness, might change favorably after exposure to informa-tion about mental illness, but this did not translate to posi-tive attitudes toward people with mental illness or amelio-rate negative perceptions after subjects viewed atelevision documentary about mental illness. Specifically,Penn et al. (2003) examined whether a documentarydepicting individuals with schizophrenia would reducestigma. One hundred sixty-three individuals viewed oneof three documentary films (on schizophrenia, polar bears,

or being overweight) or no film. The authors found thatviewing the documentary about schizophrenia resulted inless likelihood to blame persons with schizophrenia forthe disorder but had no impact on general attitudes aboutthe disorder (e.g., perceived dangerousness) or on partici-pants' intentions to interact with persons with schizophre-nia.

Walker and Read (2002) explored whether differentexplanations for mental illness (a psychosocial vs. bio-genetic/medical cause) would lead to different effects onattitudes among college students in New Zealand.Students saw one of three different 5-minute videos thatfirst showed a doctor presenting one of three causal expla-nations (medical, psychosocial, or combined) for mentalillness, followed by the same scene of a student describ-ing his symptoms. Pre- and postexposure attitude mea-sures indicated a tendency toward more negative thanpositive attitudes toward persons witii mental illness. Useof a medical explanation did not improve attitudes, and infact, perceptions of dangerousness and unpredictabilitywere stronger among participants viewing the video withthe medical explanation. The authors found that personswith previous contact with someone who had used psychi-atric services had more positive attitudes.

One study found that a mediated message plus con-tact with a person with mental illness was more influentialon attitudes than a message alone. Tolomiczenko et al.(2001) examined the impact of a video that described asuccessful story of homeless persons with mental illnesson attitudes of viewers toward tiiose individuals depicted.Nearly 600 high school students in Canada participated inone of three (control, video, or video plus discussion witha homeless person) versions of a 2-hour course. Theauthors found that females and persons with previousencounters with homeless persons had more positive atti-tudes after the educational session. However, when con-trolling for these effects, the video alone had a negativeimpact on attitudes compared to the other groups, and thevideo plus discussion had the most positive impact. Theauthors conclude that contact with members of stigma-tized groups is important to reduce negative attitudes.

Using Media as a Tool for Change

If the mass media can have a negative influence on theperception of mental illness, it is reasonable to expect thatit should also be able to exert a positive influence toreduce stigma. The synthesis of findings from research onthe role of the media in mental illness as well as otherareas suggests the need to understand two processes ofmessage production and how they work together. The firstinvolves a better understanding of the nature of the mes-sages and how more appropriate messages might be

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developed. The second involves a better understanding ofthe role of media content producers (i.e., writers, journal-ists, newspaper editors, and producers of televisionshows, newscasts, or movies) in creating these messages.Can there be a shift to portrayals of mental illness that areunbiased and fair and that present the many points of viewof people involved in mental health care? If so, howmight this shift be accomplished?

One possible answer may be revealed by analyzingthe production procedures of entertainment and news togain an understanding of the forces that shape the mes-sage. Some researchers (Signorielli 1989; Nairn 1999;Salter and Byrne 2000) suggest that to challenge andchange the media's current practices, the needs, values,and economic realities of journalists, screenwriters, andother producers of mass-mediated messages must beunderstood. Few empirical studies have explored mediacontent producers' attitudes and knowledge about mentalillnesses. Grierson and Scott (1995) found some evidencethat producers of print news stories have more enlight-ened views of persons with mental illness than do the gen-eral population. Following a telephone survey of residentsof Alabama, researchers mailed survey questions to edi-tors and managing editors in Alabama. Results indicatethat editors are less likely than the general public to con-sider persons with mental illness as dangerous and unpre-dictable, but editors also express resistance to hiring per-sons with mental illness.

The very nature of news production may influencethe framing of mental illness in the mass media. First,conventional wisdom would suggest that more accurateinformation about mental illness will foster greaterknowledge and more positive attitudes. Nairn et al. (2001)found that factual, correct information is often accuratelyrepresented in the media. However, while these news sto-ries are based on balanced, scientific approaches, the endproduct reflects a negative slant that was absent in theoriginal materials used for the story. The researchers con-clude that to make a factual, unbiased document into anewsworthy story, the news media need to transform theinformation in a way that often results in a negative fram-ing and a nonindividualized description of a mental illnessthat corresponds to traditional, stereotypical perceptionsof these types of issues. Second, it has been suggested thatas a way to reduce stigma, psychiatrists need to be moreavailable to the media and more active as expert sourcesof information on mental illness. Nairn (1999) discoveredthat psychiatrists' opinions included in news articles werefound to be ineffective because of journalists' need to cre-ate newsworthy articles rather than positive views of men-tal illnesses. Understanding how journalists and othermedia producers have to balance newsworthiness (whichby its own nature dictates a simplistic message) and fair-

ness (which requires some level of complexity) to thesubjects of their stories and news reports, is necessary forthe media to be used as a tool for change. Allen and Nairn(1997), however, challenge the assumption that negativemedia depictions of mental illness occur because journal-ists are poorly informed or because "sensation sells."From a discourse analysis of news stories they concludethat media practices used to engage readers necessitate astyle of writing requiring readers to draw upon "common-sense knowledge" that mental illnesses make people dan-gerous and unpredictable, thereby making readers co-cre-ators of the text.

In entertainment television as well, narratives areoften formulaic. Wilson et al. (1999a) analyzed 14 NewZealand television dramas to examine how dangerousnesswas constructed in media depictions of persons with men-tal illness. Using discourse analysis to examine the pro-duction features of the programs, they identified ninedevices (appearance, music and sound effects, lighting,language, intercutting, jump-cutting, point of view shots,horror conventions, and intertextuality) as contributing tosignifying the dangerousness of the person with mentalillness. They suggest that mental health professionalsmust understand the practices and priorities of televisionproduction if they are to collaborate effectively with pro-ducers to create dramas that reflect the reality of mentalillness.

Some suggest that to change the current media land-scape, it is important to provide information and educa-tional material to journalists. Smellie (1999) proposed amental health short course for training young reportersthat would cover medical, legal, and political issues in itscurriculum, similar to the way in which journalists aretaught reporting techniques for court, police, and govern-ment beats. Furthermore, general guidelines for journal-ists have been proposed. For example, Shain and Phillips(1991) stress the importance of presenting the mental sta-tus of a person in a story only if this is relevant to thenews article. Shain and Phillips also echo the traditionalplea to journalists to use terminology with precision, fair-ness, and expertise when describing individuals with men-tal illness and their symptoms.

Identifying Gaps in the ResearchA number of gaps are evident after examining the past 10years of research on mental illness images in the media.In this section, key gaps in what is known about mentalillness in the media are identified and directions for futureresearch are suggested, addressing the three questions thathave driven this review: (1) How is mental illness por-trayed by the media? (2) How do media images of mentalillness impact individuals' knowledge, beliefs, attitudes,

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and behaviors with regard to mental illness? (3) How canmedia be used to reduce mental illness stigma?

Gaps in Media Portrayal Research. While a number ofstudies have examined the portrayal of mental illness inthe media over the past decade (20 studies of the 34 intable 1), it is difficult to draw reliable conclusions or estab-lish trends because of a number of factors. First, over halfof the studies examine media outlets outside of the UnitedStates (10 studies: 7 in New Zealand, 1 in Australia, 1 inGermany, and 1 in the United Kingdom; table 1), makingdirect comparisons impossible because of the variety ofmedia systems and cultural differences. Second, the disclo-sure of and precision of definitions are necessary for sub-sequent inference and comparison of analyses of differentstudies over time. Exactly how mental illness is definedand identified in some studies is unclear, and other studiesexamine only specific terms. Third, research has been lim-ited to a relatively narrow range of media channels, mostfrequently prime-time television, newspapers, general cir-culation magazines, and films. For example, regardingtelevision studies, research has continued to focus on net-work television to the exclusion of cable television and tofocus on prime-time television to the neglect of televisionin other portions of the day (e.g., daytime, morning), withfew exceptions. Also conspicuously absent is research thataddresses specific various forms of advertising as well asnew media. Fourth, little is known about contextual factorsthat may affect the nature of the depiction. For example,very little research has examined how different groups(e.g., consumers of mental health services, family andfriends, health care providers, employers, landlords) areportrayed in terms of demographic characteristics such asage, sex, race, and ethnicity.

Given these concerns, more systematic research thatcatalogs and monitors images of mental illness across dif-ferent genres and different media channels over timewould enable documentation of the frequency and natureof images. Recent research seems to suggest that somemedia, such as general circulation magazines (Wahl andKaye 1992), may present more accurate and positivedepictions of mental illness than other media channels,such as prime-time television dramas or print news(Diefenbach 1997; Wahl et al. 2002). Although thereseems to be a consensus that media depictions of mentalillness are associated with violence and are generally neg-ative, the current state of research cannot comment onwhether all representations of mental illness in all mediaare similar. A lack of any systematic approach to examin-ing images of mental illness across different media chan-nels over time limits the construction of a composite pic-ture of the universe of images that are typically depictedin the media. While people tend to consume a range of

different media channels in their "media diet," most previ-ous research has examined a single media channel in iso-lation. A systematic approach to monitoring images ofmental illness in the media would contribute to examiningthe "media diet" consumed by audiences and foster a bet-ter understanding of how different media work and howmessages combine to affect audiences.

Gaps in Media Impact Research. The majority ofempirical studies done in the past decade focus on mediaimpact (14 studies; table 1). In this literature, two majorsources of concern arise. One area of concern focuses onthe nature of the subjects participating in research. For themost part, the majority of research on impact has claimedto focus on the "general public" while tending to use col-lege students as the participants in studies. The use of stu-dents as convenience samples is prevalent in recentresearch and limits generalization of findings to adults inthe community. Moreover, little research attention hasfocused on how persons with mental illness perceive theeffects of images of mental illness in the media. Peoplewith mental illness are directly affected by the content ofmedia channels too, because more than 40 percent ofmental health consumers (Wahl 1999) or people who haveschizophrenia (Dickerson et al. 2002) reported that theyhad often or very often been hurt or offended by messagesin mass media. However, this audience has received littleattention in empirical research. Research is also lackingon adolescents and children, two audiences who may bemore impressionable when exposed to media images(Comstock 1993). Wahl's (2002) review underscores theneed for additional research on the impact of media onchildren's views of mental illness.

While audience characteristics are of concern, by farthe largest gap in the literature regarding mental illnessand mass media to date is a lack of empirical evidencethat links exposure to media content with depictions ofmental illness and the formation and maintenance ofknowledge, attitudes, and behaviors that perpetuate orreduce stigma. The handful of experiments (four since1990; table 1) that have been conducted to assess impacthave examined the role of information as an influence incorrecting perceptions about persons with mental illness,with special attention to participants' perceptions aboutpersons with mental illness being dangerous and unpre-dictable. However, studies are not comparable because oflimitations in methodology (e.g., lack of pre- and post-exposure measures of attitudes) and the lack of generaliz-ability of the studies because of the nature of the subjects(primarily college students). It is unclear whether mediaimages have the most impact on knowledge, attitudes, orbehaviors, or how media might best be employed to ame-liorate mental illness stigma.

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Gaps in Using Media as a Tool for Change. Researchon the content and impact of media images of mental ill-ness can also contribute to a better understanding of howmedia might be used to ameliorate mental illness stigma.However, few studies have examined directly how mediamight be used to reduce stigma (nine studies; table 1).Only four experimental studies (Thornton and Wahl 1996;Tolomiczenko et al. 2001; Walker and Read 2002; Perm etal. 2003) directly address the role of media in reducingmental illness stigma. Therefore, the cumulative findingsprovide little direction about how the content of mediamessages might be influential and warrant attention at asystem or policy level. More research should address howimages are created and disseminated by media contentproducers. Little is known about media content producersas an "audience" for messages from mental health advo-cates, consumers of mental illness, or others. In otherhealth areas, such as suicide, guidelines have been devel-oped for journalists on how best to cover suicide in thenews to limit suicide contagion or "copycat" suicides(Gould 2001). Working with media in ways such as thismay contribute to stigma reduction.

Corrigan and Penn (1999) warn that stigma is diffi-cult to change. It is not simply a question of finding themost appropriate media channel; it is necessary to focuson beliefs people have about a person with mental illnessrather than their perceptions about traits. And while pro-moting personal contact with a person with mental illnessmay be a significant factor (Holmes et al. 1999), not allcontacts are equally effective (Corrigan and Penn 1999;Sadowet al. 2002). Although real-world experience withpeople with mental illness may be pivotal in overcomingstigma, it may be that the media can also serve as changeagents when used as a proxy for promoting "personal"contact, depending on who and what is presented viawhich medium (e.g., print, video, or both) (Krauss 1995;Corrigan et al. 2001). Research on the impact of mediaimages of mental illness might look more closely at otherapproaches to stigma research that have yet to address therole of the media.

ConclusionsThe goal of this review is to identify areas where researchis needed. Studies done in the past decade are few, are lim-ited in the scope of media they address, provide very littleknowledge about the impact of media images of mental ill-ness, and observe only short-term effects. However, thepast decade of research reflects growing attention to othermedia sources besides television, including a heightenedinterest in newspapers and popular magazines, as well asthe recognition of new media as an area for exploration.Unfortunately, research is virtually nonexistent on some

types of media messages, such as advertising, and on somemedia channels and genres, such as radio and televisiontalk shows, video games, and Web sites.

While the body of research examining images ofmental illness in media is limited, the findings of thesestudies are consistent. Content analyses indicate thatmental illness is consistently misrepresented in mediadepictions through exaggerations and misinformation.Depictions are inaccurate, both in representing people asviolent and dangerous (Wahl 1992; Philo et al. 1994;Diefenbach 1997) and in the nature of the informationabout the disorders (Wahl 1992, 1995). The two out-standing conclusions of media portrayals of persons withmental illness are that they are associated with violenceand that they are dangerous and should be avoided.Attempts to examine the impact of media imagesthrough surveys and experiments generally echo theseconclusions.

Yet collectively, the findings of the 34 studiesreviewed here lend at best circumstantial evidence to sup-port the notion that media images perpetuate mental ill-ness stigma. A link between media depiction and individ-uals ' perceptions is still theoretical at this point.Replication and expansion of research in this area isrequired, and particular emphasis should be given to iden-tifying links between exposure to media images and sub-sequent impact. Experimental work in this area is espe-cially important.

Simply stated, more precise research is needed thatexamines both the content and the impact of images ofmental illness in U.S. media. Future research should usemore exactness in terminology defining mental illnessand should examine a broader range of media channelswith more discrete genres. Systematic research thatmonitors change in depictions across time and acrossthe "media diet" consumed by different audiences isneeded. The importance of replication and expansion ofresearch cannot be overstated. Before considering howmedia might be used to ameliorate mental illnessstigma, more experimental research must examinewhich media genres and channels may have which spe-cific impact on which audiences under which circum-stances. While what is known about the role of media inmental illness stigma has grown slowly over the pastdecade, this proposed research agenda offers new direc-tions for inquiry in a research area of great potentialthat needs to be nurtured.

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The Authors

Patricia A. Stout, Ph.D., is Professor, University of Texasat Austin, Austin, TX. Jorge Villegas, Ph.D., is AssistantProfessor, University of Florida, Gainesville, FL. NancyA. Jennings, Ph.D., is Assistant Professor, University ofCincinnati, Cincinnati, OH.

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Documents

Images of Mental Illness in the Media - Schizophrenia Bulletin