The picture of mental health/illness in the printed media in three Central European countries.

Abstract

Even in the era of the Internet, printed media are still among the most frequently identified sources of mental health information. Many studies have shown that this information is frequently negative and contributes to stigmatization of people with mental illness. This international comparative study describes the content of media messages about mental health/illness in terms of stigma in three Central European countries. The study sample comprised all articles pertaining to the topic of mental health/illness (N = 450) identified during five week-long periods in 2007 chosen from the six most widely read newspapers and magazines in each country. The authors used content analysis methods to achieve quantitative and qualitative objectives. More than half of all articles contained negative statements reflecting stigma toward persons with mental illness. Substance abuse disorders are the most frequent mental conditions covered in all three countries (22%), and psychotic disorders are the most stigmatized. Countries significantly differ in length of articles, in the association of aggressive behavior with persons with mental illness, and in the use of a sensationalized style of writing. Coverage of mental health/illness issues differs to some extent across countries but is generally of poor quality. On the basis of the authors' findings, practical recommendations for journalists can be tailored specifically for each country.

Full text

Page 1

The Picture of Mental Health/Illness in the Printed Media in Three
Central European Countries
LUCIE NAWKOVÁ, ALEXANDER NAWKA, and TEREZA ADÁMKOVÁ
Department of Psychiatry, First Faculty of Medicine, Charles University in Prague, Prague, Czech
Republic
TEA VUKUŠIĆ RUKAVINA
Andrija Stampar School of Public Health, Medical School, Zagreb University, Zagreb, Croatia
PETRA HOLCNEROVÁ
Department of Psychiatry, First Faculty of Medicine, Charles University in Prague, Prague, Czech
Republic
MARTINA ROJNIĆ KUZMAN and NIKOLINA JOVANOVIĆ
Department of Psychiatry, University Hospital Centre, Medical School, Zagreb University, Zagreb,
Croatia
OGNJEN BRBOROVIĆ
Andrija Stampar School of Public Health, Medical School, Zagreb University, Zagreb, Croatia
BIBIÁNA BEDNÁROVÁ, SVETLANA ŽUCHOVÁ, MICHAL MIOVSKÝ, and JIŘÍ RABOCH
Department of Psychiatry, First Faculty of Medicine, Charles University in Prague, Prague, Czech
Republic
Abstract
Even in the era of the internet, printed media are still among the most frequently identified sources
of mental health information. Many studies have shown that this information is frequently
negative and contributes to stigmatization of people with mental illness. This international
comparative study describes the content of media messages about mental health/illness in terms of
stigma in three central European countries. The study sample comprised all articles pertaining to
the topic of mental health/illness (N=450) identified during five week-long periods in 2007 chosen
from the six most widely read newspapers and magazines in each country. Content analysis
methods were used to achieve quantitative as well as qualitative objectives. More than half of all
articles contained negative statements reflecting stigma towards persons with mental illness.
Substance abuse disorders are the most frequent mental conditions covered in all three countries
(22%) and psychotic disorders are the most stigmatized. Countries significantly differ in length of
articles, the association of aggressive behavior with persons with mental illness, and in the use of a
sensationalized style of writing. Coverage of mental health/illness issues differs to some extent
across countries, but is generally of poor quality. Based on our findings, practical
recommendations for journalists can be tailored specifically for each country.
Broadcast and printed media are considered to be the public’s primary source of information
regarding mental health/illness (e.g., Anderson, 2003; Hannigan, 1999; Philo, Secker, Platt,
Henderson, McLaughlin, & Burnside, 1994). Numerous studies have documented an
association between negative media portrayals of people with mental illness and the public’s
Address correspondence to Lucie Nawková, Department of Psychiatry, First Faculty of Medicine, Charles University in Prague, Ke
Karlovu 11, 128 00, Prague, Czech Republic. lucie.nawkova@gmail.com.
NIH Public Access
Author Manuscript
J Health Commun. Author manuscript; available in PMC 2013 January 1.
Published in final edited form as:
J Health Commun. 2012 ; 17(1): 22–40. doi:10.1080/10810730.2011.571341.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 2

negative attitudes (e.g., Angermeyer & Matschinger, 1996; Philo, 1996; Wahl, 1992; Wahl
& Lefkowits, 1989), and have concluded that stigmatizing presentations have a direct
negative impact on individuals living with mental illness (Grinfeld, 1998) as well as on
social policies (Cutcliffe & Hannigan, 2001; Olstead, 2002; Rose, 1998).
Numerous researchers have investigated the representations of mental illnesses in the printed
media. Many of them have suggested that depictions of mental illnesses are relatively
common in printed media and that these provide a distorted depiction of people with mental
illnesses, highlighting their bizarre features (e.g., Coverdale, Nairn, & Claasen, 2002; Day &
Page, 1986; Hazelton, 1997). Several studies also repeatedly confirmed that many depictions
convey a greatly exaggerated connection between mental illness and aggressive behavior
(e.g., Allen & Nairn, 1997; Slopen, Watson, Gracia, & Corrigan, 2007). Those articles were
also more often published on the first page of daily newspapers and journals, increasing their
potential to influence readers (e.g., Boke, Aker, Sarisoy, & Sahin, 2007; Corrigan, Watson,
Gracia, Slopen, Rasinski, & Hall, 2005; Ward, 1997).
Few relevant investigations have been conducted in Central and Eastern Europe. A Serbian
study of the representations of mental illness in the press found that depictions of mental
illness were considerably negative, presenting people with mental illness as dangerous and
as victims of their health conditions (Bilic & Georgaca, 2007). In the Czech Republic, these
issues were investigated mainly in relation to the image of drug abuse and drug users in
printed media (Grohmannova, 2006; Miovska, Brachova, & Miovsky, 2008; Sivek,
Miovska, & Miovsky, 2004).
Situation in the Czech and Slovak Republic
The Czech Republic with population of 10.2 million (Eurostat, 2010) and the Slovak
Republic with population of 5.4 million (Eurostat, 2010) once was a single country. The
history of psychiatry and mental health care issues is therefore very similar, as is the socio-
cultural background. During the communist era of 1948 – 1989, the one-party system with a
centralized economy and substantial restrictions of democratic rights influenced all aspects
of society (Dragomirecka, Brazinova, Palova, Baudis, & Selepova, 2008; Vevera, 2004).
The health care system was nationalized and patients did not have free choice of a specialist
or treatment facility. No civic movements or non-governmental organizations (NGOs)
existed to provide advocacy, promotion, or prevention. The communist regime monopolized
the media and largely prevented any alternative voices from reaching the public. The main
political, social, and administrative changes after the “Velvet Revolution” in November
1989 provided the basis for creation of new mental health policies, which enabled attempts
to address stigma (Dragomirecka et al., 2008; Vevera, Hubbard, Vesely, & Papezova, 2005).
In 2004 the Czech Republic joined the World Psychiatric Association (WPA) program
entitled “Open the Doors” with the initiative called Zmena (Change). Its survey focused on
schizophrenia revealed that there is little knowledge about the disease among the general
public and that stereotypes about the dangerousness and unpredictability of patients are
widespread (DEMA, 2004). Because mental health literacy was found to be very low in
Czech Republic, one of the main priorities of the other initiative Stop stigma is to increase
the level of information on mental illness mainly by encouraging media to provide more
complete and accurate information (Stop stigma, 2009).
The League for Mental Health is a leading NGO active in mental health promotion and
protection in the Slovak Republic (Liga za dusevne zdravie, 2008). Its programs include
media campaigns on alcohol abuse and schizophrenia. Another Slovak national
organization, Otvorme dvere otvorme srdcia (Open the door open your hearts), implements
the anti-stigma program of the WPA (Sartorius, 2005). In cooperation with the media, this
NAWKOVÁ et al.Page 2
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 3

program included interviews with patients and their relatives appearing in newspapers as
well as on television (Nawka, 2005).
Situation in Croatia
Croatia with population of 4.4 million (Eurostat, 2010), has a very similar socio-cultural and
historical background of psychiatry and mental health care to the Czech and Slovak
Republics. Croatia was part of Yugoslavia, with the communist regime in place until 1991.
After the Croatian Parliament declared the independence and sovereignty of the country, by
the Yugoslav Army started an open military conflict that lasted until the liberating military
events of 1995 marked the end of the war. Since 1991, thorough transitional changes took
place and brought vast socioeconomic, political and cultural changes. These changes also
affected overall health issues and mental health issues as well. Ten percent of the adult
population are war veterans who suffer from psychiatric problems, especially post-traumatic
stress disorder (PTSD). Prevalence of PTSD ranges from 18-40% (Komar & Vukusic, 1999)
and the suicide rate among war veterans is more than twice as high as for the general
population (Suicidi info, 2009). Throughout the 1991 – 2004 period, 1053 war veterans
committed suicide (Croatian Government, 2006).
Recent findings report a high level of stigma towards mental illness as reported by the
general population, medical staff, and caregivers of patients with mental illness (Arbanas,
2008; Filipcic, Marcinko, Grubisin, Begic, Tomac, & Dordevic, 2003), mostly associated
with fear and insufficient knowledge about psychiatric patients and mental disorders. A
recent study of PTSD and perception of stigma showed that stigma perception depends on
social support and intensity of symptoms (Aukst-Margetic, Toic, Furjan Boban, & Margetic,
2009).
Even though the above figures show a dramatic situation, the Croatian government has still
not accepted international standards of anti-stigma programs from the World Health
Organization (WHO) or WPA. Therefore anti-stigma programs are mostly provided by
NGOs or psychiatric associations. Mental health professionals are making efforts to provide
anti-stigma programs and some positive results have been already achieved through the
establishment of a Center for Mental Health at the Health Centre Zagreb and Croatian
Center for Rehabilitation in Community, Vrapce Psychiatric Hospital, as a part of the
WHO’s and Stability Pact pilot project (Health development action for south-eastern
Europe, 2009).
Objectives
Our study aimed to compare the contents and tone of articles on mental health/illness in
Czech, Croatian, and Slovak print media. An international comparison should provide
comprehensive information on representations of mental illnesses in printed media in each
country, which can be a basis for targeted anti-stigma programs with respect to socio-
cultural contexts. The main goals of our study were to determine how many articles on
mental health/illness issues were published during the defined period and how was the tone
of the articles regarding stigmatization of people with mental illness. Who is the source of
information, what types of mental disorders are described in the articles, and how violence
connected with people who are mentally ill is presented were secondary goals.
NAWKOVÁ et al.Page 3
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 4

Methods
Study sample
Our study sample comprised articles pertaining to the topic of mental illness chosen from
the six most widely-read daily newspapers in print and six most widely-read weekly
periodicals in print in each country. Articles related to mental health/illness were retrieved
by media retrieval agencies. They were taken from four one-week periods randomly selected
from every three months throughout 2007 plus one week randomly selected from the year
2007. All parts of the newspapers were searched for the key words covering the topic of
mental illness, including news, interviews, columns, and editorials.
To achieve the objectives of this research, we employed content analysis, a quantitative and
qualitative research method used for systematic and verifiable description of media content
based on scientifically-based questioning (McQuail, 1999; Schulz, Hagen, Scherer, &
Reifova, 1998). It is highly structured and intended for processing large amounts of data,
thus enabling adequate statistical analysis of the results.
Keywords
Keywords were divided into two groups as follows, neutral terms (e.g. psychiatry,
depression, anorexia) and labeling terms (mental illnesses expressions are used as labels,
e.g. schizophrenic, alcoholic, neurotic).
Sampling
Out of all articles obtained after setting the keywords, we analyzed only those in which the
subject of mental health/illness represented the main content. The initial numbers of articles
identified were 102 in Croatia, 1424 in the Czech Republic, and 900 in Slovakia. The
selection of articles with mental health/illness as main content enabled us to perform a more
comprehensive analysis of the way in which these issues are reported in all three countries.
Coding manual
The coding manual was developed specifically for this study based on the theoretical
framework of content analysis (Kerlinger, 1972; Schulz et al., 1998). To further improve
codes for this study we conducted a focus group with four mental health professionals and
two journalists. Various issues regarding journalistic style and the way of reporting on
mental illnesses were discussed.
The coding manual comprises two parts: identifying categories and analytical categories.
Identifying categories were used for easy identification of separate items and for finding the
links with analytical categories; the latter served as the basis for answering the key research
questions. Identifying categories included name of the article, date of issue, name of the
media, type of the media, page, and number of words.
The articles were also coded for the types of disorders named and described and for the
sources of information about mental illness, e.g. inclusion of perspectives from mental
health experts, persons with mental illness, or their families. Disorders that were included
generally corresponded to classifications from the International Classification of Diseases
(ICD-10, 1993).
All categories were determined a priori by the research team during several workshops and
were used as a basis for consensual coding. In determining the analytical categories we tried
to cover main issues such as sensationalism, aggression, global impression of the heading,
and global impression of the article, all of which have proven crucial in previous studies. In
NAWKOVÁ et al.Page 4
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 5

the category of “sensationalism” we focused both on content and form of the article. The
first is based on the focus of the article, includes topics such as celebrity, speculations or
scandal. The form reflects the language style (appellative expressions, superlatives or
colloquial terms). Likewise, aggression was assessed also by two separate categories. In the
category “aggressive behavior”, we focused on whether the person with mental illness was
depicted as a perpetrator or a victim of violent acts. In the second category we identified the
particular type of aggressive act. In assessing the global impression of the article the items
were evaluated according to the presence of positive/negative statements and coded as either
negative, positive, mixed, or neutral. Each analytical category included a paragraph-long
definition to facilitate coding.
To reflect the overall conclusion or main emphasis of the article, single statements
pertaining to the topic of mental health/illness were analyzed using constant comparison of
content method (Strauss & Corbin, 1998).
Coding process
Each article was coded by three separate in-country coders. Reliability for the analytical
categories among raters in all three countries was assured by their uniform training and
regular international meetings in which they discussed possible differences in interpretation.
During the pilot study, 30 exemplary articles were translated into all languages and all raters
coded them to compare connotations among the languages. Inter-rater reliability among
coders was determined for analytical categories of the articles by Average Pair-wise Percent
Agreement (APPA). APPA for the categories “aggressive act” and “aggressive behavior”
was more than 88% in all three countries; lower APPA scores were determined for
categories “sensationalism” and “global impression.” Since these results showed less
satisfactory APPA scores, the final coding in these categories was always reached by
consensus of all three raters in each country.
Statistical analysis
Descriptive statistics were used to present all data obtained from the total sample. The
differences of frequencies among countries were determined using χ2 tests or with non-
parametric tests, as appropriate after testing for distribution. P values less than 0.05 were
considered statistically significant. All statistical analyses were carried out with the SPSS
13.0 (SSPS inc., Chicago, IL, USA) statistical software package.
To describe the effect of particular variables on the global impression, we introduced a
variable negative/positive ratio (NPR). This variable uses only two clusters (articles coded
as positive and negative). Articles coded as neutral and mixed were not included in this
analysis. Higher NPR shows a stronger effect on negative global impression.
Results
General information
A total of 450 articles related to mental health issues were identified for the five weeks
sampled for the study (Croatia 75, Czech Republic 203 and Slovak Republic 172). Some of
the main characteristics (distribution of the articles among different type of print media,
articles positioned with headline on cover, and disorders mentioned) are presented in Tables
1 and 2. The mean number of words per article across all three countries was 237. A larger
word count was associated with more positive global impression. The mean number of
words in articles with positive global impression was 278, whereas the mean number of
words in articles with negative global impression was 175 (Kruskal Wallis Test, p<0.001).
The most frequently described psychiatric disorders among the articles analyzed were
NAWKOVÁ et al.Page 5
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 6

substance abuse disorders. In a large proportion of the articles no specific psychiatric
disorder was mentioned (Croatia 24%, Slovakia 30.2% and Czech Republic 36.5%). The
opinion of a mental health professional was sought in one-third of the articles and people
with mental illness were quoted in about 10% of all articles. Mental health professionals
were listed as a source of information in 61.6% of the positive articles, compared to only
16.3% of the negative articles.
Aggressive behavior and aggressive acts
Aggressive behavior was associated with persons with mental illness in 49.3% of articles in
Croatia, 24.6% of articles in Czech Republic and 40.1% of articles in Slovakia (see Table 1).
In the “aggressive act” category people with mental illness were predominantly presented as
dangerous, involved in crime-related stories such as committing homicide (Croatia 48.7%,
Slovakia 30.2% and Czech Republic 27.0%), or physical assault (Croatia 30.8%, Slovakia
25.7% and Czech Republic 20.7%). These items included messages such as “a 59-year old
woman attacked her sleeping co-patient in the ward block of a psychiatric department.
Without the intervention of a passerby witness, she would have beaten her victim to death
with a chair.”
Global impression and sensationalism
Based on the coding manual’s main category of “global impression,” we have coded articles
as positive, neutral, mixed, or negative, according to the presence of positive and/or negative
statements about mental illness/health. Negative articles were almost equally distributed
among all three countries: 37.4% of articles in the Czech Republic, 38.4% of articles in the
Slovak Republic, and 40.0% articles in Croatia. Examples included items such as “a furious
man was raging in the street, behaving out of control. Police patrol transferred him to the
psychiatric department; he suffered from schizophrenia.” Aggressive behavior of a mentally
ill person (perpetrator, victim or both) was described in 60.5% of the negative articles,
versus only 5% of the positive ones. As for the specific aggressive acts, homicide was found
in 24.4% of the negative articles and physical assault in 19.7%. None of the positive articles
were associated with aggressive acts committed by mentally ill persons. The largest
proportion of articles with sensationalized content as well as form was found in Croatia
(Table 1). The majority of these included the use of terms such as “never-ending affliction,”
“sad ending,” or “demons in the head.” In all three countries, a neutral tone in headlines was
predominant. Positive tone represented the smallest group with 11% in all countries,
including titles such as “Prague launches helpline.” A negative tone was found in
approximately one-third of the headlines (Table 2); examples included “Mother gone mad”
and “Insane man pacified by the police.” Ninety-four percent of articles having a headline
that was positive in tone were positive too. Similarly, 80% of those articles with a negative
headline were negative as well.
Predictors of negative and positive impression of the article
NPR represents a simple “predictor” of negativity of articles within a particular category.
Categories with the highest NPR ratio are: tabloids, stigmatizing headline, the headline of
the article on the cover, and psychotic disorders mentioned in the article (Table 2). Positive
global impression of the article is more frequently found in the articles from magazines, in
the articles about anxiety and eating disorders, and when a mental health professional or
scientific survey were used as sources of information. Among all three countries, articles
from Croatia have the highest NPR of 5 vs. 1.6 in Czech Republic or 1.4 in Slovakia.
NAWKOVÁ et al.Page 6
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 7

Main message of the article
The positive/negative statements from the articles were grouped accordingly to their
common features in order to form meaningful sub-groups and groups, reflecting overall
conclusion or main emphasis of the article. Four groups were identified - mental illness as a
medical condition, mental illness and society, psychiatric services, and mental illness and
aggression. Subsequent sub-groups and examples of the statements are shown in Table 3.
Discussion
This is the first comparative study on mental health/illness issues in the printed media in the
three central European countries of Croatia, the Czech Republic and Slovakia. Compared to
similar studies, mostly conducted in English speaking countries - Australia (Francis, Pirkis,
Blood, Dunt, Burgess, Morley & Stewart, 2005), Canada (Day & Page, 1986; Stuart, 2003),
New Zealand (Coverdale et al., 2002), USA (Corrigan et al., 2005), UK (Philo, 1996) and a
few others - Serbia (Bilic & Georgaca, 2007), Italy (Carpiniello, Girau, & Orru, 2007),
Turkey (Boke et al., 2007), some new observations are worth mentioning. These include the
length of the article and its impact on the global impression of the article, the relationship
between the coding of the headline and the article itself, and the vast disconnection between
the real prevalence of some disorders and their coverage in the printed media.
We collected 450 articles in the study, which amounts to an average of 30 articles with
mental health/illness issues each week in each country in the most read newspapers and
magazines. In our opinion this is a relatively high number compared to the space devoted to
articles related to other medical specialties and their patients. This finding might be
promising, suggesting a growing understanding of the importance of mental health/illness in
the society, but in the light of the following discussion this hopeful assumption fades.
More important than the absolute numbers of how many articles are represented in each
media type (broadsheets: 256, tabloids: 153, and magazines: 41) was the different
distribution of articles according to the coding of global impression. Whereas broadsheets
and magazines were almost equally represented in all four categories (in positive and neutral
as well as in mixed and negative), tabloids clearly dominated in the category of negative
articles (89 articles out of 153).
A closer look at the number of articles that were published on the front page reveals another
interesting finding. The NPR of 3.7 for the front page articles is higher compared to the later
sections where NPR=1.7, thus augmenting the negative impact of the story on the public.
The explanation seems clear: negative stories attract more attention and therefore sell the
media product better than positive ones (Stuart, 2003). Interestingly, major differences
regarding the prevalence of violence are not found among articles from later sections.
The most surprising result was the vast difference in the length of the articles when grouped
in positive and negative clusters. “Positive” articles were more than 50% longer than
“negative” ones. This finding may be an unfortunate result of today’s journalistic practice
where space on the page means money. Correct expressions such as “a person with
schizophrenia” are replaced with the label “schizophrenic” and facts on therapy and
recovery are dispensable. This finding corresponds to articles in magazines having a much
better NPR of 0.6 compared with broadsheets (NPR=1.0) and especially tabloids
(NPR=6.8). One conclusion could be that longer articles are more positive because the
journalist has more room to give accurate details.
A similar study completed in Australia (Francis, Pirkis, Blood, Dunt, Burgess, Morley,
Stewart, & Putnis, 2004) found that 19.3% articles in newspapers were related to depression,
NAWKOVÁ et al.Page 7
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 8

a finding comparable to what we have found in all three countries (18.7%). In contrast to
Croatia and the Slovak Republic, where the coverage of affective disorder was higher
(20.0% and 25.6% respectively), in the Czech Republic we found only 12.3 % of the articles
covered these conditions. Although much has been done to raise awareness of depression in
the Czech Republic, it seems that more progress is still needed in this sphere. Interestingly,
it appears that substance abuse disorders at least seem to be covered according to their real
prevalence in the three countries, as the use of alcohol and so-called “soft drugs” is
relatively high compared to other regions. All three countries are in the top ten countries in
Europe regarding alcohol consumption (WHO, Alcohol consumption and harm, 2009). This
is not the case, however, when comparing the correlation of actual rates of mental illness in
the populations for other conditions (schizophrenia and eating disorders over-represented,
anxiety disorders, dementia, on the other hand, under-represented).
Disturbing to us was that only five articles out of 60 where psychosis was mentioned were
coded as positive, with similar results across countries. Psychosis seems to be the most
stigmatized mental disorder, a result also found in several similar studies (e.g., Boke et al.,
2007; Francis et. al., 2004; Nairn et al., 2001; Stuart, 2003). Building upon the results of
recent study among German citizens, even improving mental health literacy about mental
illnesses and in particular about schizophrenia does not necessarily lead to improvement of
public attitudes toward people with mental illness (Angermeyer, Holzinger, & Matschinger,
2009). Combating the prejudice against this severe mental condition remains one of the
biggest challenges for the anti-stigma campaigns in Central Europe also. On the other hand
eating disorders achieved the best score from all mental disorders, where NPR=0.3.
Until now, countries in Central Europe have not been well represented in the long list of
studies that have found a connection between mental health/illness issues and violence
(Allen & Nairn, 1997; Corrigan et al., 2005; Philo et al., 1994; Ward, 1997). The one
exception is a Serbian study (Bilic & Georgaca, 2007) that revealed that the topic of
dangerousness of individuals with mental disorders was present in approximately one-third
of all newspaper articles. A similar study conducted in Great Britain came to the conclusion
that 46% of articles contained references to crime (Ward, 1997). These numbers are very
close to our findings, although they vary among the countries studied. Notably, the rates of
articles dealing with aggression of people with mental illness is much higher in Croatia
(49%), which might be related to the recent 1991-1995 war. Even though the suicide rate has
decreased in the post-wartime period (Bosnar, Stemberga, Coklo, Zamolo Koncar, Definis-
Gojanovic, Sendula-Jengic, & Katic, 2005), cases of suicide attempts and completed
suicides among veterans with PTSD are not rare (Loncar, Definis-Gojanovic, Dodig,
Jakovljevic, Franic, Marcinko, & Mihanovic, 2004) and significant attention is still paid to
these incidents in the Croatian printed media. Nevertheless, in all three countries the level of
portrayal of individuals with mental illness as perpetrators of aggressive acts is high even
though studies have shown that individuals with mental disorders who are not also using
drugs or alcohol are not significantly more likely to commit violent crime than the general
population (Steadman, Mulvey, Monahan, Robbins, Appelbaum, Grisso, Roth, & Silver,
1998; Ward, 1997).
In a contrary finding, very little attention is paid to individuals with mental illness as victims
of acts of aggression, even though victimization is more common than aggressive behavior
by these individuals (Hodgins, Cree, Alderton, & Mak, 2008). When analyzing what kind of
aggressive acts are most often connected with individuals with mental illness, we can say
that hetero-aggressive acts (homicide, physical assault, and aggression against objects)
outnumbered the auto-aggressive ones (committed or attempted suicide, self-harm) almost
two-fold in the Czech Republic, three-fold in Slovakia and nine-fold in Croatia.
NAWKOVÁ et al. Page 8
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 9

Interestingly when mixed and negative articles, i.e. those containing at least some negative
statements, were collapsed into one category, it included more than half of all articles in the
Czech Republic and Slovakia and more than three-quarters in Croatia. As much as these
findings may be discouraging for mental health consumers, the more it should encourage all
anti-stigma campaigners to continue their efforts. These negative stereotypes result in
decreased life opportunities and loss of independent functioning of persons with mental
illness (Henderson & Thornicroft, 2009; Hinshaw & Stier, 2008).
Although individuals with mental illness or their families appeared in some articles as
sources of information, those articles tended to be negative rather than positive (NPR=1.8).
This is in contrast to other studies which showed that presentation of mental illnesses in the
form of self-portraits by the affected persons resulted in their positive image accentuating
their ability to overcome stigma (Byrne, 2003; Nairn & Coverdale, 2005). This is also in
contrast with recommendations for responsible journalism, which suggest that articles that
involve individuals with mental illness and their families should focus not only on
symptoms or consequences of the illness, but also on therapy and recovery, showing a more
positive picture of living with mental illness (Nairn, 1999). It seems not to be the case in the
three countries studied. We have also found that 36% of articles had quotes or perspectives
of mental health professionals which is significantly higher than the 15% reported by Wahl
and coauthors from the USA (Wahl, 2001). In contrast with the negative impact of
presenting the patients as a source of information, we have found an association between the
presence of a mental health professional in the story and a positive global impression rating
(NPR=0.5). This is also consistent with previous research comparing media representations
of general medical issues with psychiatric ones. Where general medicine has a “bad doctor”
focus, psychiatry has a “bad patient” angle (Byrne, 2000). An even greater predictor of
positive outcome than inclusion of a mental health professional is reference to a scientific
survey (NPR=0.1).
Our qualitative analysis revealed what topics are dealt with articles related to mental illness.
The first group consists of articles describing mental illness as a “medical condition”,
including prevention, treatment, as well as its consequences. The biggest group consisted of
articles in relation to “society”, in which dominated the issues of stigmatization and politics.
“Psychiatric services” group was represented with leading themes; misuse of psychiatry and
quality of mental health care. In many articles “aggression” connected with mental illness
presented the fundamental motive and was therefore identified as a group.
Several limitations of this study should be mentioned and considered in future research.
First, the results relate to five one-week periods, so some stories may have been over-
represented or missed completely. Secondly, the sample of the articles could be limited by
keywords that we set. Third, the smaller number of articles in Croatia might have resulted
from the use of a different type of search service provided by agencies collecting the
articles. In contrast to the Czech and Slovak web-based search engines using only key
words, the Croatian agency used real people who excluded the articles that did not have
mental health/illness as a main topic of the article. Some of the relevant articles could have
been overlooked due to this different approach. Finally, our analyses are based on a rater’s
interpretation of the articles and on the final joint agreement of all raters in each country.
Consensus ratings minimize unreliability for within-country rating but cannot control for
unreliability among country ratings. As in almost all other studies in this field, only written
materials are analyzed, so important visual information, such as photos, are omitted in the
coding process. This might shift the final coding on the axis from positive to negative, or
just as likely in the other direction.
NAWKOVÁ et al.Page 9
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 10

The media representations of mental illness reported in this paper show a few common
features across the countries that we studied. We report a similarly high level of negative
articles and very bad coverage of persons with psychosis in general, as well as a few
differences, such as more frequent coverage of aggressive behavior in association with
mental illness in Croatia or longer articles on mental health/illness issues published in
Slovakia. Not unexpectedly, in many of the characteristics studied the Czech Republic and
Slovakia are much closer to each other than to Croatia. This might be explained by a long
history of shared journalism practice, similar political, social and economical factors, as well
as absence of recent war.
Even though mental health professionals in Croatia have created recommendations for
responsible suicide reporting (Suicidi Info, 2006), results of this study show that more effort
and productive collaboration has to occur to achieve a more positive picture of mental
illness in the Croatian printed media. Since Croatia has a history of joint education of health
professionals and health journalists, through the annual “Media and Health” course (Vukusic
Rukavina, Brborovic & Harapin, 2007), this joint educational experience could serve as a
starting point for the development and implementation of broader recommendations
(covering not only suicides) for responsible reporting about mental illnesses. Recently, in
the Czech Republic and in the Slovak Republic, press conferences for health journalists have
been introduced. Some encouraging changes following these interventions might be tracked,
as journalists have been in closer contact with mental health professionals. These new
activities, however, are just the initial steps in what must be a longer-term effort at
improving mutual collaboration. Moreover, the authors of this study intend to share our
findings with students of journalism, who are the primary target group of such campaigns, as
they are the future of journalism in all three countries. This study serves as a basis for those
educational campaigns and is tailored specifically for each country involved in this study.
The ultimate goal of this effort is to improve media coverage of mental health/illness issues,
minimize potential discriminatory practices, and increase help-seeking behavior.
Acknowledgments
We would like to thank our senior advisors Prof. Howard Goldman and Prof. Stephen Hinshaw for their
unwavering support. This project was prepared within the “Finance and Mental Health Services Training in Czech
Republic/Central Europe,” sponsored by the U.S. National Institutes of Health John E. Fogarty International Center
(5 D43 TW005810-07) and with support of the grant titled “The Development of a Coding System for Social-
Psychological Quantitative Content Analysis of Media Messages and the Possibilities of Combination with
Qualitative Methods” GAČR 406/07/0541.
References
Allen R, Nairn RG. Media depictions of mental illness: An analysis of the use of dangerousness.
Australian and New Zealand Journal of Psychiatry. 1997; 31:375–381. [PubMed: 9226083]
Anderson M. One flew over the psychiatric unit: mental illness and the media. Journal of Psychiatric
and Mental Health Nursing. 2003; 10:297–306. [PubMed: 12755914]
Angermeyer MC, Holzinger A, Matschinger H. Mental health literacy and attitude towards people with
mental illness: A trend analysis based on population surveys in the eastern part of Germany.
European Psychiatry. 2009; 24:225–232. [PubMed: 19361961]
Angermeyer MC, Matschinger H. The effect of violent attacks by schizophrenic persons on the attitude
of the public toward the mentally ill. Social Science and Medicine. 1996; 43(12):1721–1728.
[PubMed: 8961416]
Arbanas G. Adolescents’ attitudes toward schizophrenia, depression and PTSD. Journal of
Psychosocial Nursing and Mental Health Services. 2008; 46(3):45–51. [PubMed: 18416274]
Aukst-Margetic B, Toic G, Furjan Boban A, Margetic B. Stigma and posttraumatic stress disorder.
European Psychiatry. 2009; 24(1):18.
NAWKOVÁ et al.Page 10
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 11

Bilic B, Georgaca E. Representations of “Mental Illness” in Serbian Newspapers: A Critical Discourse
Analysis. Qualitative Research in Psychology. 2007; 4:167–186.
Boke O, Aker S, Aker AA, Sarisoy G, Sahin AR. Schizophrenia in Turkish newspapers. Social
Psychiatry and Psychiatric Epidemiology. 2007; 42:457–461. [PubMed: 17502973]
Bosnar A, Stemberga V, Coklo M, Zamolo Koncar G, Definis-Gojanovic M, Sendula-Jengic V, Katic
P. Suicide and the war in Croatia. Forensic Science International. 2005; 147:13–6. [PubMed:
15541586]
Byrne P. Stigma of Mental Illness and ways of diminishing it. Advances in Psychiatric Treatment.
2000; 6:65–72.
Byrne P. Psychiatry and the media. Advances in Psychiatric Treatment. 2003; 9:135–143.
Carpiniello B, Girau R, Orru MG. Mass-media, violence and mental illness. Evidence from some
Italian newspapers. Epidemiologia e Psichiatria Sociale. 2007; 16(3):251–255. [PubMed:
18020199]
Corrigan PW, Watson AC, Gracia G, Slopen N, Rasinski K, Hall LL. Newspaper stories as a measure
of structural stigma. Psychiatric Services. 2005; 56(5):551–556. [PubMed: 15872163]
Coverdale J, Nairn R, Claasen D. Depictions of mental illness in print media: A prospective national
sample. Australian and New Zealand Journal of Psychiatry. 2002; 36(5):697–700. [PubMed:
12225457]
Croatian Government – Press release from the round table about suicides of Croatian war veterans.
[Retrieved from the Web September 27, 2009] 2006.
http://www.vlada.hr/hr/naslovnica/priopcenja_za_javnost/2006/svibanj/
potpredsjednica_vlade_otvorila_okrugli_stol_samoubojstva_hrvatskih_branitelja_i_mogucnosti_p
reventivnog_djelo vanja
Cutcliffe JR, Hannigan B. Mass media, “monsters” and mental health clients: The need for increased
lobbying. Journal of Psychiatric and Mental Health Nursing. 2001; 8(4):315–321. [PubMed:
11882144]
Day DM, Page S. Portrayal of mental illness in Canadian newspapers. Canadian Journal of Psychiatry.
1986; 31:813–817.
DEMA. Nazory na schizofrenii [Opinions on Schizophrenia]. Reprezentativni vyzkum v CR; Praha:
2004.
Dragomirecka, E.; Brazinova, A.; Palova, E.; Baudis, P.; Selepova, P. The history of mental health
care in Czechoslovakia. In: Scheffler, R.; Potucek, M., editors. Mental Health Care Reform in the
Czech and Slovak Republics, 1989 to the Present. Karolinum Press; Praha: 2008. p. 29
[Retrived from the Web January 29, 2010] Eurostat. Total population.
http://epp.eurostat.ec.europa.eu/tgm/table.do?
tab=table&language=en&pcode=tps00001&tableSelection=1&footnotes=yes&labeling=labels&pl
ugin=1
Filipcic I, Marcinko D, Grubisin J, Begic D, Tomac A, Dordevic V. Attitudes of general population in
Croatia towards the psychiatric label “schizophrenic patient” tested by an anti-stigma
questionnaire (in Croatian). Socijalna psihijatrija. 2003; 31:3–9.
Francis C, Pirkis J, Blood RW, Dunt D, Burgess P, Morley B, Stewart A, Putnis P. The portrayal of
mental health and illness in Australian non-fiction media. Australian and New Zealand Journal of
Psychiatry. 2004; 38(7):541–546. [PubMed: 15255827]
Francis C, Pirkis J, Blood RW, Dunt D, Burgess P, Morley B, Stewart A. Portrayal of depression and
other mental illnesses in Australian nonfiction media. Journal of Community Psychology. 2005;
33(3):283–297.
Grinfeld MJ. Psychiatry and mental illness: Are they mass media targets? Psychiatric Times. 1998;
15(3)
Grohmannova K. Stimulancia a opioidy z pohledu medii. Adiktologie. 2006; 6:242–257.
Hannigan B. Mental health care in the community: an analysis of contemporary public attitudes
towards, and public representations of, mental illness. Journal of Mental Health. 1999; 5:431–440.
Hazelton M. Reporting mental health: a discourse analysis of mental health-related news in two
Australian newspapers. Australian and New Zealand Journal of Mental Health Nursing. 1997;
6:73–89. [PubMed: 9256656]
NAWKOVÁ et al. Page 11
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 12

[Retrieved from the Web September 12, 2009] Health development action for south-eastern Europe
(SEE) – Mental health project. http://www.euro.who.int/stabilitypact/projects/20040611_3
Henderson C, Thornicroft G. Stigma and discrimination in mental illness: Time to change. Lancet.
2009; 373(9679):1928–1930. [PubMed: 19501729]
Hinshaw SP, Stier A. Stigma as related to mental disorders. Annual Review of Clinical Psychology.
2008; 4:367–393.
Hodgins S, Cree A, Alderton J, Mak T. From conduct disorder to severe mental illness: associations
with aggressive behaviour, crime and victimization. Psychological Medicine. 2008; 38(7):975–87.
[PubMed: 17988416]
WHO; Geneve: 1993. ICD-10 Classification of mental and behavioural disorders.
Kerlinger, FN. Zaklady vyzkumu chovani. Academia; Praha: 1972.
Komar, Z.; Vukusic, H. Post-traumatic stress disorder in Croatian war veterans: Prevalence and
psycho-social characteristics. In: Dekaris, Dragan; Sabioncello, Ante, editors. New insights in
post-traumatic stress disorder (PTSD). Proceedings (Abstracts, references and illustrations).
Croatian Academy of Science and Arts; Zagreb: 1999. p. 42-44.
[Retrieved from the Web December 3, 2008] Liga za dusevne zdravie.
http://www.dusevnezdravie.sk/odos.html
Loncar C, Definis-Gojanovic M, Dodig G, Jakovljevic M, Franic T, Marcinko D, Mihanovic M. War,
mental disorder and suicide. Collegium Antropologicum. 2004; 28:377–384. [PubMed: 15636097]
McQuail, D. Uvod do teorie masove komunikace. Portal; Praha: 1999.
Miovska L, Brachova H, Miovsky M. Obsahova analyza medialnich sdeleni o drogach v CR.
Alkoholizmus a drogove zavislosti. 2008; 43(4):193–204.
Nairn R. Does the use of psychiatrists as sources of information improve media depictions of mental
illness? A pilot study. Australian and New Zealand Journal of Psychiatry. 1999; 33:583–589.
[PubMed: 10483855]
Nairn R, Coverdale J. People never see us living well: An appraisal of the personal stories about
mental illness in a prospective print media sample. Australian and New Zealand Journal of
Psychiatry. 2005; 39:281–287. [PubMed: 15777366]
Nairn R, Coverdale J, Claasen D. From source material to news history in New Zealand print media: A
prospective study of the stigmatizing process in depicting mental illness. Australian and New
Zealand Journal of Psychiatry. 2001; 35:654–659. [PubMed: 11551282]
Nawka, P. Slovakia. In: Sartorius, N.; Schultze, H., editors. Reducing the stigma of mental illness. A
report from a Global Program of the World Psychiatric Association. Cambridge University Press;
Cambridge: 2005. p. 108
Olstead R. Contesting the text: Canadian media depictions of the conflation of mental illness and
criminality. Sociology of Health and Illness. 2002; 24:621–643.
Philo G, Secker J, Platt S, Henderson L, McLaughlin G, Burnside J. The impact of the mass media on
public images of mental illness: Media content and audience belief. Health Education Journal.
1994; 53:271–281.
Philo, G. The media and public belief. In: Philo, G., editor. Media and Mental Distress. Addison
Wesley Longman; Essex: 1996.
Rose D. Television, madness and community care. Journal of Community & Applied Social
Psychology. 1998; 8:213–228.
Sartorius, N. Developing the programme. In: Sartorius, N.; Schultze, H., editors. Reducing the stigma
of mental illness. A report from a Global Program of the World Psychiatric Association.
Cambridge University Press; Cambridge: 2005. p. 7-12.
Schulz, W.; Hagen, L.; Scherer, H.; Reifova, I. Analyza obsahu medialniho sdeleni. Karolinum Press;
Praha: 1998.
Sivek V, Miovska L, Miovsky M. Obraz uzivatelu a uzivani konopnych drog v ceskych mediich v roce
2003. Adiktologie. 2004; 4:474–492.
Slopen NB, Watson AC, Gracia G, Corrigan PW. Age analysis of newspaper coverage of mental
illness. Journal of Health Communication. 2007; 12:3–15. [PubMed: 17365345]
NAWKOVÁ et al. Page 12
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 13

Steadman HJ, Mulvey EP, Monahan J, Robbins PC, Appelbaum PS, Grisso T, Roth LH, Silver E.
Violence by people discharged from acute psychiatric inpatient facilities and by others in the same
neighborhoods. Archives of General Psychiatry. 1998; 55(5):393–401. [PubMed: 9596041]
[Retrieved from the Web January 12, 2010] Stop stigma.
<http://www.stopstigmapsychiatrie.cz/cile-zmeny.html>
Strauss, A.; Corbin, J. Basics of Qualitative Research: Techniques and Procedures for Developing
Grounded Theory. Second Edition. Sage Publications; 1998.
Stuart H. Stigma and the daily news: Evaluation of a newspaper intervention. Canadian Journal of
Psychiatry. 2003; 48(10):651–656.
[Retrieved from the Web September 12, 2009] Suicidi info – Portal za prevenciju suicida.
http://www.suicidi.info/epidemiologija.asp
[Retrieved from the Web June 15, 2010] Suicidi info – Portal za prevenciju suicida.
http://www.suicidi.info/ieNews/clanak.asp?ID=1
Vevera J, Hubbard A, Vesely A, Papezova H. Violent behavior in schizophrenia. Retrospective study
of four independent samples from Prague 1949 to 2000. British Journal of Psychiatry. 2005;
187:426–30. [PubMed: 16260817]
Vevera J. Problems and goals in the US psychiatry and its application for Czech psychiatric care.
Česká a slovenská psychiatrie. 2004; 4:134–140.
Vukusic Rukavina, T.; Brborovic, O.; Harapin, M. Media and Health. In: Donev, D.; Pavlekovic, G.;
Kragelj, L. Zaletel, editors. Health promotion and disease prevention. Hans Jacobs Publishing
Company; Hellweg: 2007. p. 256-67.
Wahl OF. Commentary. Current Opinion in Psychiatry. 2001; 14:530–531.
Wahl OF. Mass-media images of mental-illness - A review of the literature. Journal of Community
Psychology. 1992; 20:343–352.
Wahl OF, Lefkowits JY. Impact of a television film on attitudes toward mental illness. American
Journal of Community Psychology. 1989; 17(4):521–528. [PubMed: 2610206]
Ward, G. Making headlines. Mental health and the national press. Health Education Authority;
London: 1997.
World Health Organization. [Retrieved from the Web September 3, 2009] Alcohol consumption and
harm. 2009. http://data.euro.who.int/alcohol/Default.aspx?TabID=4936
NAWKOVÁ et al.Page 13
J Health Commun. Author manuscript; available in PMC 2013 January 1.
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Page 14

NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NAWKOVÁ et al.Page 14
Table 1
Main characteristics of the studied articles
Feature
Total sample
N=450
N (%)
Croatia
N=75
N (%)
Czech Rep.
N=203
N (%)
Slovak Rep.
N=172
N (%)
Test (among countries)
Pearson Chi-Square
Media type
Tabloids
153 (34)
0 (0)
75 (37)
78 (45)
Χ2=62,965,df=4,
p<0.001
Broadsheets
256 (57)
70 (93)
115 (57)
71 (41)
Magazines
41 (9)
5 (7)
13 (6)
23 (14)
Headline on
the cover
Yes
34 (8)
4 (5)
26 (13)
4 (2)
Χ2=15,284, df=2,
p=0.001
No
416 (92)
71 (95)
177 (87)
168 (98)
Disorder
mentioned
(chosen
groups)
F00.0 – F09.9
16 (4)
0 (0)
6 (3)
10 (6)
Χ2=51.718 df=10,
p<0.001
F10.0 – F19.9
118 (26)
32 (43)
53 (26)
33 (19)
F20.0 – F29.9
60 (13)
12 (16)
19 (9)
29 (17)
F30.0 – F39.9
84 (19)
15 (20)
25 (12)
44 (26)
F40.0 – F49.9
38 (8)
14 (19)
8 (4)
16 (9)
F50.0 – F50.9
37 (8)
5 (7)
19 (9)
13 (8)
Sensational
content
Yes
160 (36)
36 (48)
57 (28)
67 (39)
Χ2=10.888, df=2,
p=0.004
No
290 (64)
39 (52)
146 (72)
105 (61)
Sensational
form
Yes
139 (31)
55 (73)
50 (25)
34 (20)
Χ2=76.983, df=2,
p<0.001
No
294 (69)
20 (27)
153 (75)
138 (80)
Aggressive
behavior
Perpetrator
115 (26)
31 (41)
32 (16)
52 (30)
Χ2=5,303, df=6,
p=0.258
Victim
26 (6)
5 (7)
11 (5)
10 (6)
Both
15 (3)
1 (1)
7 (4)
7 (4)
None
294 (65)
38 (51)
153 (75)
103 (60)
Aggressive
act
Autoaggr.
31 (7)
3 (4)
15 (7)
13 (8)
Χ2=30.688,df=6,
p=0.006
Hetero-aggr.
120 (27)
35 (47)
36 (18)
49 (28)
Both
25 (5)
1 (1)
12 (6)
12 (7)
None
274 (61)
36 (48)
140 (69)
98 (57)
Length
of the
article
Mean number
of words
237
200
239
250
Kruskal Wallis Test
Chi-Square=8,325, df=1,
J Health Commun. Author manuscript; available in PMC 2013 January 1.

Page 15

NIH-PA Author Manuscript
NIH-PA Author Manuscript
NIH-PA Author Manuscript
NAWKOVÁ et al. Page 15
Feature
Total sample
N=450
N (%)
Croatia
N=75
N (%)
Czech Rep.
N=203
N (%)
Slovak Rep.
N=172
N (%)
Test (among countries)
Pearson Chi-Square
p=0.004
F00.0 – F09.9 Organic mental disorders (Dementia)F10.0 – F19.9 Mental and behavioral disorders due to psychoactive substance useF20.0 – F29.9 Schizophrenia, schizotypal and delusional disordersF30.0 – F39.9 Mood [affective] disorders F40.0 – F49.9 Neurotic, stress-related and somatoform disordersF50.0 – F50.9 Eating disorders
J Health Commun. Author manuscript; available in PMC 2013 January 1.