Media and mental illness: Relevance to IndiaSK Padhy, S Khatana, S Sarkar
Department of Psychiatry, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 24823515
Source of Support: None, Conflict of Interest: None
Media has a complex interrelationship with mental illnesses. This narrative review takes a look at the various ways in which media and mental illnesses interact. Relevant scientific literature and electronic databases were searched, including Pubmed and GoogleScholar, to identify studies, viewpoints and recommendations using keywords related to media and mental illnesses. This review discusses both the positive and the negative portrayals of mental illnesses through the media. The portrayal of mental health professionals and psychiatric treatment is also discussed. The theories explaining the relationship of how media influences the attitudes and behavior are discussed. Media has also been suggested to be a risk factor for the genesis or exacerbation of mental illnesses like eating disorders and substance use disorders. The potential use of media to understand the psychopathology and plight of those with psychiatric disorders is referred to. The manner in which media can be used as a tool for change to reduce the stigma surrounding mental illnesses is explored.
Keywords: Media, mental illness, portrayal, psychiatric
The term media collectively refers to the main means of mass communication. The means of media can be in the form of Internet (the World Wide Web), television, radio, newspapers, magazines, newsletters and various forms of print media. The primary aim of the media is communication, with the goal of educating, informing and entertaining the audience. Media acts as a mirror of the society and, in turn, influences the perception and behavior of individuals.
Media and mental illnesses interact with each other in many complex ways as shown in [Figure 1]. Media may act as the primary source of information about mental illnesses and may shape the perceptions and attitudes about mental illnesses. Media portrayal may stigmatize mental illnesses as well as act as a means of reducing inaccurate perceptions. Media can act as risk factors for certain forms of mental illnesses. Specific forms of media, especially films, can be used as a means of understanding psychiatric disorders and the treatment methods that are available.
India being the largest democracy and with fairly unrestricted media is likely to be a case in point about how media influences the perception of mental illnesses. This narrative review takes a look at the interface of media and mental illnesses from various perspectives, including how media portrays mental illnesses, how it impacts patients with mental illnesses, how it can act as a risk factor for mental illnesses, how it can be used to understand psychopathology and how it can be used as a tool for change.
It has been shown that media portrayal can influence one's perception about mental illnesses. Media influence can override personal experiences in relation to how mental illness are viewed. , Media can perpetuate the negative stereotypes associated with mental illnesses. Often, persons with mental illness are depicted with negative attributes like being unlikable, dangerous, aggressive, violent, asocial, untrustworthy and incompetent. ,,,,, Media reports of homicides attributed to the mentally ill seem to be depicted in a more stigmatizing manner as if to emphasize that they were different from homicides committed by others.  Labeling people with mental illnesses as dangerous and violent reinforces the public view of fear and anxiety toward the mentally ill. ,
Perpetuation of stigma by the media towards mental illness is an important problem that requires concerted attention. , One feature of depiction of mental illness in the media is the omission of specifics. Often, the description is carried out of a "psychiatric patient" or "mentally ill." Because there is a variety of mental disorders each with different manifestations, giving a common label to all may lead people to generalize. , The qualifiers like "severe" if used indiscreetly may lead to an inaccurate portrayal of mental disorders and misunderstanding of psychiatric diseases. Movies like "Psycho" and "Halloween0" may increase the anxiety and fear about the mentally ill patients among the general public and lead to further distancing and stigmatization. 
Whether particular forms of media impart a balanced view of the mentally ill has been scrutinized. Some forms of media like general circulation magazines have been suggested to present a more accurate and positive depiction of mental illness than prime time television. , Individuals who reported receiving their information primarily from the electronic media (e.g., television, film) reported less tolerance toward individuals with mental illness than those receiving information primarily from the print media. 
Media not only portrays mental illness in a negative manner but, at times, also provides positive depictions. Movies, newspapers, magazines and newsletters have made attempts to correctly inform and educate people about mental illnesses. Personal accounts of patients and sensitive depictions in movies like "As Good As It Gets" have attempted to deliver a fairly accurate image of psychiatric illnesses and their sufferers. Mass media provides an opportunity to fill the knowledge gaps of the general public about mental illnesses. Whether the gap is filled by accurate and correct description or by inaccurate inflated reports remains a question that requires consideration. This question is especially important as the knowledge about psychiatric illnesses is generally low in India and misconceptions about mental illnesses abound. 
As with mental illnesses, media portrayal of psychiatrists and mental health professionals might not have been always positive. They were quite often portrayed as neurotic, unable to maintain professional boundaries, substance users, rigid, controlling, ineffectual, uncaring, self-absorbed or mentally unstable.  In very few films like Good Will Hunting (1997) and Ordinary People (1980) have they been depicted as empathic. In Indian cinema too, as in the West, psychiatrists have been caricatured and at times shown as vile or unprofessional. ,
In both Bollywood and Hollywood movies, the depictions of psychiatric treatment, especially electroconvulsive therapy (ECT), were inaccurate, distorted and dramatized. ECT was shown to be administered by force to punish, to torture, to obliterate identity and to induce insanity.  The clinical evidence of safety and usefulness of ECT, which is one of the most effective forms of psychiatric treatment in severe mental illness, had been largely overlooked.  ECT treatment has been depicted to cause mental disturbance and amnesia without clinical improvement in movies like Raja, Damini, Khamoshi, Jewel Thief, Rat aur Din, etc. , Other extreme forms of treatment like lobotomy and forced medication have been depicted in movies without a clear indication and rationale, suggesting a rather coercive side to psychiatric treatment. 
It seems likely that psychopharmacological treatments have been subjected to a negative portrayal too. Psychotropic drugs have been found to have a lower acceptance than cardiac drugs, and were believed to cause significantly more severe side-effects and provoke more fear of losing control. Such opinions rather seemed to be fueled by media reports.  Psychotropic drugs are apparently discussed less objectively in the medical context than the other medications.  Such negative attitudes have been apparently decreasing with time. 
At times, live electronic and print media give a comparatively positive picture of psychiatrists and psychiatric treatments. Some magazines and newspapers publish columns and write-ups about psychiatric illnesses and their treatment, and aim to dispel myths. Live chats and interviews also give an opportunity to hear out practicing professionals and ask pertinent questions about psychiatric disorders.
Attempts have been made to understand how media imparts knowledge and influences the attitudes, behaviors and views of individual. Two mass communication theories are particularly relevant in this regard: The "social cognitive theory"  and the "cultivation theory."  A major component of social cognitive theory is "symbolizing capability," which means that people process and transform transient experiences into cognitive models using symbols that act as guides for judgment and action. Depictions of people who are mentally ill act as symbols of mental illness as a whole and can also provide viewers with the virtual experience of what a person with a mental illness must be like. Television is a primary example of a tool used to provide people with such vicarious experiences. Heavy exposure to these vicarious experiences may become reality to the viewer through the cultivation theory. The cultivation theory states that the more one views certain material, the more likely it becomes the reality for him, i.e. people who watch a lot of television are more likely to express opinions and hold values similar to those represented on television and the content watched.
Whether media predisposes a person to mental illness has been a matter of query. The association of media and various mental illness and psychiatric disorders has been evaluated.
Media and eating disorders
Exposure of women to glamorously thin images in the media has been suggested to lead to body image dissatisfaction and low self-esteem. This has been suggested to lead to a drive for thinness and a quest for dieting, which may result in eating disorders. ,,, It is difficult to conclude whether media plays a causal role, acts as a trigger or is just another confounder for those who are otherwise predisposed. It is possible that only those individuals having pre-existing anxiety, depression, low self-esteem or genetic liability are vulnerable to cultural demand and develop symptoms of eating disorders.
Regional variations exist in the body image dissatisfactions in relation to the media. In Iran, ban on Western media after the fall of the Shah precluded being exposed to the thin body beauty, leading to a higher body esteem of Iranian female students.  Eating disorders had not been recorded until the advent of televised media on the Fiji islands. , Countries like India and China also reported cases of eating disorders after 1990 with wider exposure to the Western media.  Muscular dysmorphia, a type of "reverse anorexia" in males with preoccupation on muscle bulk, has emerged as a male counterpart of anorexia nervosa seemingly fuelled by media portrayal of lean and muscular men. 
Media and suicide
The role of fictional portrayal of suicide-leading imitative acts began in the late 18 th century, when Goethe released his novel "The Sorrows of Young Werther," wherein the protagonist ends his own life due to unrequited love. A few deaths by the same means as the protagonist led to use of the term "Werther effect" to describe the hypothesized association between media portrayal of suicide and imitative acts by observer. Such imitative suicidal behavior has been observed worldwide.  In India, Chowdhury et al.  reported 18 cases of copycat suicides after media reports of a judicial hanging, and 17 other imitation acts. Such copycat suicides and attempts have even been observed in young children,  and have otherwise led to political repercussions. 
Many factors have been evaluated as risk factors of imitative suicidal behaviors. It has been seen that imitative suicides are more common within 2 weeks of the first event, with greater media coverage, repeated coverage and high-impact stories, when the person described in the story and the reader/viewer are similar in some way, when the person described in the story is a celebrity and is held in high regard by the reader/viewer and particular subgroups in the population (e.g., young people, people suffering from depression and substance use disorder). ,,, Farmer suicides is another issue that has been highlighted by the media, constructively raising awareness about the stress and plight of the farmers  and sensitizing the authorities. 
Media and substance use
Media can play a key role in the initiation and accentuation of substance use. Research has revealed that advertising may be responsible for up to 30% of adolescent tobacco and alcohol use. , Exposure to tobacco marketing and advertising increases the smoking initiation rates in teenagers more than two-fold.  Advertisements and promotion of cigarettes have been increasing in developing countries like India due to a sharp decline in sales in Western countries, and pose as a major concern. 
Media research also shows that, alcohol and tobacco appeared in the majority of the movies. Illicit drugs were commonly shown in a large proportion of movies  as well as through the television.  Characters in the movies or television are often shown smoking as a part of daily life. Covert sponsoring of mega sport events like international cricket matches and bravery awards surreptitiously aim to promote tobacco products. These may attract the vulnerable adolescents toward smoking as a desirable "grown up" activity.  A study from India suggests that those children who are exposed to cigarette brand names through television are more likely to smoke, while those exposed to anti-tobacco messages are less likely to smoke.  Such marketing strategies need to be countered to reduce initiation to substance-taking behaviors.
Media and internet addiction
Internet addiction has emerged as a new form of behavioral addiction with the popularization and easy access of the World Wide Web.  Dependence on the Internet seems to have criteria similar to that of pathological gambling and other substance use disorders. It has been seen that Internet addiction is present in a significant proportion of the youth in countries like South Korea and Taiwan.  It has been suggested that Internet addiction coexists with other psychiatric disorders like substance use disorder, attention deficit hyperactivity disorder, depression and anxiety. , Because India also possesses a gradually expanding Internet-using population, it is likely that Internet addiction and comorbid problems would be encountered more frequently. 
Media and sexual behavior
Media in the form of television, magazines or movies has been found to be an important source of sexual information to the teenagers.  Adolescents who selectively viewed more sexual content on television were more likely to have sexual intercourse in the preceding year. , Media exposure to pornography may lead to experience of conflict, suffering and sexual dissatisfaction.  Media exposure to sexual themes may have a negative effect on the attitudes toward women, and may portend to a greater propensity to indulge in coercive intimate encounters and experimentation. ,, On the other side, when used correctly, media can have significant positive impacts on sexual health-related attitudes, beliefs and behaviors. , Mass media can provide knowledge about healthy sex, contraception, family planning, sexually transmitted diseases and treatment of sexual disorders. Viewing advertisements about human immunodeficiency virus (HIV) have led to a reduction in the reported number of sexual partners by both men and women and increased condom usage.  In India too, mass media including television and radio were the most important sources of information about HIV.  Several international studies have found that women who view more family planning messages on television, radio and print media are more likely to use contraceptives than those who see fewer messages. ,
Media and depression
Exposure to significant levels of television and other electronic media during the teenage years has been suggested to influence depression during young adulthood, especially among men.  Media exposure at night may disrupt sleep, which is important for normal cognitive and emotional development. In addition, messages transmitted through the media may lead to fear, anxiety and aggression. The new face of social media in the form of Facebook and others may cause depression in teenagers.  The association between social media use and depression may not be a very robust one as there evidence to the contrary.  Whether media multitasking is used by persons who are depressed and anxious as a means of distraction needs to be evaluated. 
The rise and acceptance of social media has been particularly marked in India. Although it may act as a means of making friends and gathering social support, it may lead to stress in some individuals.  Because social media websites are among the most commonly accessed websites in India with a large quantum of users,  it is likely that social media may negatively affect a large segment of the population through concerns about social image.
Media and post-traumatic stress disorder (PTSD)
Media viewing of tragic events may produce PTSD symptoms in vulnerable populations such as children. It was seen that 5.4% of children who indirectly witnessed through media the terrorist attacks of 11 September 2001 developed symptomatic PTSD.  The amount of television viewing predicted increased risk of PTSD. Similarly, in adults, PTSD symptoms markedly developed in those who had high-trait anxiety and were exposed through the media to the terrorist attacks. 
Media and aggression
The potential relationship between media exposure to violence and subsequent violent behavior has been a matter of clinical enquiry for quite some time. Reports have shown that childhood television watching is associated with higher rates of aggression in later life. , The time spent on the media devices has been found to be a better marker of further violent behavior than the actual content.  On the other hand, there are studies to suggest that television violence does not influence children's behavior or make them excessively prone to violence. , Neurogenetic and environmental factors apparently interact to increase the risk of the development of aggression in violence-prone personalities.  Media may just act as a stylistic catalyst, i.e. when an individual with high-violence proneness decides to act violently, he or she may model it on what was encountered through media. However, because aggression is multifactorial in origin, no single factor including media influence can be pinned down as a dominant influence. 
Media to understand psychopathology
Media can be used to understand psychopathology and learn about mental illnesses. Although movies are rarely made to depict psychiatric illnesses per se, they often aim to show real human beings with emotions and afflictions. Psychiatric disorders that are out of the ordinary experience are often used to build characters that intrigue and entice. Such character depictions may provide an opportunity to understand psychopathology in a far interesting manner rather than conceptualizing from books. Some of the representative movies with depiction of specific psychiatric disorders are shown in [Table 1].
Through movie club discussions, psychopathology can be deliberated and understood better.  It can be used to understand the dynamics of suicide - about the intent to die and the wish to be rescued, which have been depicted in films like Scent of a Woman (1992), Ordinary People (1980) and Night Mother (1986). Traumatic experiences related to dissociative disorders include death, witnessing death or exposure to death (as in Three Faces of Eve).  Bipolar disorders have been suggested to fuel the creative process of numerous artists and composers, and some of the movies have been able to capture this effectively, e.g. Patch Adams (1998). Movies can be helpful in understanding not only specific psychiatric disorders but also for unconscious defense mechanisms, e.g. altruism of a doctor who devotes himself to people in India in City of Joy (1992), suppression in Gone with the Wind (1939) and intellectualization in Lorenzo's Oil (1992).
Indian cinema has also aptly depicted psychiatric ailments. ,, While Raaz deals with personality disorder, Taare Zameen Par takes dyslexia as a theme of the movie. Devdas dwells on alcohol abuse and dependence and My Name is Khan talks about Asperger's disease. Indian cinema is among the most productive in terms of the number of films made per year, and many other examples abound about the depiction of psychiatric disorders.
Apart from cinema, the television and print media in the form of books and magazines can be useful in understanding psychopathology. Therein too, the character development recourses on certain attributes placed on the protagonist and the other supporting individuals.
Media portrayal can influence those who suffer from psychiatric disorders. About half of the patients with mental health disorders reported that media coverage had a negative impact of their lives, about one-third reported that it increased their anxiety and depression and one-fourth endorsed that they had hostile behaviors from their neighbors due to newspaper reports.  Patients with mental illness are usually shown as victims of verbal and/or physical abuse in entertainment media, who when pushed "too far" become dangerously aggressive and even violent.  Being stressed and the trauma of being victimized can increase an individual's sense of vulnerability to further victimization and exacerbation of symptoms of the mental illness.  Negative portrayals of mental illness has been suggested to interfere with the social integration of patients with psychiatric illnesses and hamper their self-image and family life.  Not only the patients but also their families can be affected due to "courtesy stigma." The most common depictions of mental illness in the popular media involving mentally ill people as violent and criminal is not in keeping with the epidemiological data that suggests that rates of violence with only schizophrenia are not greater than that in the general population. 
Media can have an impact on the course and outcome of mental illness. Stigma due to negative media reporting can impair the self-confidence, impede recovery and create barrier for seeking treatment. , Stigma due to negative media coverage can increase anxiety, distress and depression and cause hesitancy in disclosing difficulties.  People who suffer from a mental illness may internalize negative references and develop avoidant coping mechanisms that become obstacles to treatment. Experiences of discrimination and violence can result in psychological distress.
Additionally, inaccurate portrayals of mental illness and psychiatry in films may have a range of adverse effects, including promoting inaccurate knowledge in the society, accentuating negative attitudes, increasing the stigma perceived by patients, their families and mental health professionals and causing patients to be less willing to seek psychiatric help. ,
Media is a tool that can be effectively used to increase knowledge, create favorable attitudes and change overt behavior.  If the media can exacerbate stigma in the field of mental illness, it is reasonable to assume that media can be used to reduce stigma as well. , When used correctly, media can have significant positive impacts on health-related attitudes, beliefs and behaviors. Documentary films can be used to educate the general public about mental health and disease. Viewing a documentary about schizophrenia led schizophrenia to be perceived as less dangerous.  Reading an article containing corrective information has led to a greater acceptance of persons with mental illness and less fear about mental illnesses.  Keeping this in view, the National Mental Health Program of India has attempted to use media publicity to reduce the stigma and encourage treatment seeking. The new Mental Health Care Act also aims to use media to dissipate effectively the various provisions relating to the new law. 
The manner of media reporting can also have an important influence on the behavior of the people. It has been seen that introduction of media guidelines regarding reporting suicides on the Vienna subway resulted in a reduction in the rate of suicide.  Correspondence with newspaper editors led to a marked change in the manner in which suicides are reported in the press.  Thus, collaboration with the media can help in reducing the stigma toward mental illnesses and implementing strategies to reduce harm.
Various guidelines have been developed with regard to reporting by media, especially about suicide. , These are aimed at reducing the negative impact of suicide through the media - either in the form of copycat suicides or exacerbation of stigma. The essential elements of these guidelines are as shown in [Table 2]. Although specific guidelines are available for suicide, similar responsible reporting of the psychiatric illnesses is also likely to prevent misconceptions about psychiatric illnesses.
Similarly, suggestions have been made about how psychiatrists and mental health professionals should interact with the media while discussing about psychiatric illnesses. A sensitive use of language and terminology that preserves the dignity of those with mental illnesses, and at the same time avoids miscommunication, is beneficial. Interaction with media should be taken as an opportunity to dispel myths and give a clear account of the psychiatric illnesses in question. Speculation should be avoided and clear information should be provided about how to avail services when in need.
Media and mental illnesses interact in many ways and have a complex relationship. Accurate information and proper terminology about mental illness is essential to reduce the stigma of mental illness among the general population. In order to deliver an expert source of information about mental illness through media, more psychiatrists needs to be available to the media. More importantly, language plays a role in stigma associated with mental illness and should be sensitive to the concerns of the mentally ill.
Additionally, it needs to be highlighted that media usage seems to be associated with specific psychiatric problems. Whether causation can be implicated (and direction thereof if implicated) is not fully clear in many of those instances. Still, the role of the media in these situations, like depression and eating disorders, merits further ardent research. Media portrayal can be effectively used to understand and teach about the psychiatric problems.
It must be duly acknowledged that over a period of decades, media depiction of mental illnesses has improved. Media has been playing a constructive role in mental health promotion, conveying reversibility of psychiatric problems and highlighting the importance of family and societal support for recovery. However, more needs to be done to improve the portrayal of the mentally ill.
It must be realized that the media exists primarily to inform and entertain and, as such, the motive may not concur with that of a health professional. Hence, the valuable asset of media in the form of wide reach should be used as an ally rather than as an adversary to deliver the required benefits to the patients. Hopefully, with time, effort and a constructive dialogue, media would be able to reduce the stigma associated with mental illnesses and remediate the misconceptions.
[Table 1], [Table 2]