Media and Madness

On April 16, 2007, a South Korean student named Seung-Hui Cho shot and killed 32 people and then turned the gun on himself at Virginia Polytechnic Institute in the deadliest shooting rampage in American history. Within hours after the massacre, it was widely reported that the killer had been a loner with a history of bizarre behavior who frightened some of his teachers and fellow students. He apparently had a history of psychiatric illness and had once been hospitalized.

This national tragedy was front-page news for weeks, igniting the usual debates about gun control, campus security, and even immigration. Nightly newscasts reported "no known motive" and focused on the gunman's anger, sense of isolation, and preoccupation with violent revenge. No one who read or saw the coverage would learn what a psychotic break looks like, nor that the vast majority of people with mental disorders are not violent. This kind of contextual information is conspicuously missing from major newspapers and TV.

Hollywood has also benefited from a long-standing and lurid fascination with psychiatric illness reflected by such characters as Norman Bates, the psychotic killer in Alfred Hitchcock's Psycho, and Dr. Hannibal Lecter, the cannibalistic psychiatrist in The Silence of the Lambs. Other Hollywood portrayals of mental illness -- oppressive Nurse Ratched?s wards in the screen adaptation of Ken Kesey's One Flew Over the Cuckoo's Nest, or the spurned and psychotic lover, Alex, in Fatal Attraction -- indelibly shaped public consciousness as well. Exaggerated characters like these may help make "average" people feel safer by displacing the threat of violence to a well-defined group.

But the reality is that when it comes to mental illness, there really is no "us versus them." The reason is simple and sobering: An estimated 46 percent of American adults experience some type of diagnosable mental illness or substance-abuse disorder during their lifetime, according to the National Comorbidity Survey Replication, one of the nation's most reliable surveys of mental-health disorders. One percent, one of every 100 adults, suffers from schizophrenia. Close to 17 percent battle major depression in their lives. So one way or another, most of us are affected by the mental health of our friends and relations.

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Both the news media and the entertainment industry have a critical role to play in informing public opinion. Together and separately, they can either perpetuate the stigma and misunderstanding surrounding mental illness or they can work to enlighten and educate. Indeed, there is a long tradition of investigative reporting that has had a powerful and positive impact on public policy and thinking about mental health. The intrepid journalist Elizabeth Cochrane (a k a Nelly Bly) feigned insanity in 1887 and got herself admitted to the Women's Lunatic Asylum on Blackwell's Island in New York on an undercover assignment for Joseph Pulitzer's newspaper, The New York World. Bly soon discovered that it was easier to get admitted than discharged. After 10 days, she was released from the asylum only after Pulitzer interceded on her behalf. Her undercover exposé of the brutal and inhumane conditions, later published in a book, Ten Days in a Mad-House, led to increased funding for the care of the mentally ill: The New York City Department of Corrections and Charities received an appropriation of $850,000, a 57 percent increase over the previous year.

Decades later, an unlikely group of Americans became advocates for mental-health reforms. During World War II, an estimated 3,000 conscientious objectors to the war worked as attendants at state mental hospitals and institutions for the developmentally disabled. Often sponsored by pacifist religious organizations like the Quakers and Mennonites, these young aides helped fill severe shortages of doctors and other medical personnel called to war duty. Appalled by the conditions -- overcrowding, neglect, and even brutality -- many sought to advocate on their patients? behalf through the press and public officials. In 1946, Life Magazine published a gripping photo essay based partly on the aides' first-hand accounts titled, "Bedlam 1946: Most U.S. Mental Hospitals are a Shame and a Disgrace." Similarly, social historian and journalist Albert Deutsch relied on testimony from the conscientious objectors and others when he published The Shame of the States (1948), a powerful indictment of state-run mental hospitals. Together, these and other exposés of the time increased public awareness of the plight of psychiatric patients, and some reforms were made.

In a similar spirit, Geraldo Rivera, using a smuggled key to gain entrance, exposed the horrifying conditions of Willowbrook State School for the mentally retarded on WABC-TV in 1972. Within weeks of his shocking exposé, a class-action lawsuit was filed against the Staten Island institution. It culminated in a federally enforced consent decree mandating immediate improvements at Willowbrook and other institutions, and requiring Willowbrook residents to be transferred to small, community-based residences. This, along with the advent of modern antipsychotic medications, touched off the largest mass deinstitutionalization in the nation's history. It wasn't until 1987 that the notorious facility was shuttered for good. And there's another important legacy: Largely on the basis of Rivera's report and related publicity, Congress in 1980 passed the Civil Rights of Institutionalized Persons Act. To this day, the statute empowers federal officials to investigate and sue state and local institutions -- including homes for the mentally ill and developmentally disabled but also juvenile-detention centers, nursing homes, and prisons -- for any abuse or neglect of persons in their care.

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Media coverage of mental health -- or any topic, for that matter -- can be technically accurate yet misleading, overreporting negative stories about people with mental illness, for instance, or leaving out important data. Though very different in intent, the effect is comparable to that of the pharmaceutical industry in reporting the results of new drug trials: The industry is all too eager to tell the public the good news about its drugs, but it often withholds publication of negative studies that show the new drug is no better than a placebo. This was documented in a January 2008 study in The New England Journal of Medicine involving 74 clinical trials with 12 different antidepressants, which reported that 97 percent of positive studies were published, versus only 12 percent of negative studies.

Another troubling way in which media coverage skews public understanding is in the implied link between mental illness and violence. It will surprise most people -- and disappoint Hollywood -- but the fact is that the mentally ill are rarely violent and contribute very little to overall violence in the United Sates. It is estimated that only 3 percent to 5 percent of all violence in the country can be attributed to mental illness.

In contrast to a serious psychiatric disorder like schizophrenia or bipolar disorder, drug abuse is strongly linked to violence. People with no mental disorder who abuse alcohol or drugs are nearly seven times as likely as those without substance abuse to be violent, according to the National Institute of Mental Health.

The fact is that you have far more to fear from an intoxicated businessman in a suit than from a homeless schizophrenic man muttering on the street corner. This is not something most people know because a drunken disorderly man in a suit is not deemed a newsworthy event, but the rare schizophrenic who acts violently and gets arrested is likely to find himself on the front page of a local newspaper.

The epidemiologic reality that the vast majority of mentally ill people are not violent stands in stark contrast to the impression most Americans get from the popular media. And for a good reason: Studies consistently show that most news reports about people with mental illness focus on dangerousness and violence. In a representative survey of 70 major U.S. newspapers, Dr. Patrick Corrigan at the Center for Psychiatric Rehabilitation in Evanston, Illinois, reported in 2005 that 39 percent of all stories published about the mentally ill focused on dangerousness -- the single largest area of the media's coverage of mental health. In contrast to stories that discussed mental-health treatment or public policy, those that touched on violence were also far more likely to be front-page news.

Popular media affect not just how the public views people with psychiatric illness but how the public thinks about the disorders themselves. A recent article in The New York Times discusses the issue of mental-health insurance parity. In comparing mental to physical illness, it asks, "If mental illness never ends, which is typically the case, how do you set a standard for coverage equal to that for physical ailment, many of which do end?" The question repeats a common misconception about mental illnesses, namely, that they are unremitting and untreatable. In fact, major mental disorders are quite treatable and have response rates to psychosocial and biological treatments that are on par with, if not better than, common nonpsychiatric medical illnesses.

Diseases like diabetes, hypertension, coronary artery disease, and arthritis are chronic illnesses that, like psychiatric disorders, are treatable but not curable. What makes psychiatric disorders different from medical ones is that they manifest by changes in thinking, feeling, and behavior instead of physical signs like fever and rash. But brain disorders are every bit as real in the physical sense as medical diseases. Neuroscience research has made clear that major psychiatric illnesses like depression and schizophrenia are associated with changes in brain function and circuitry.

But the public has little sense from stories in the popular media that mentally ill people can get better with treatment, recover, and go on to lead productive lives. The old dictum, "if it bleeds it leads," still determines what is deemed newsworthy.

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What can the popular media do, then, to cover mental health accurately but avoid reports on mental illness that are biased and gratuitously negative? Since there is no escaping bad news, it should be standard journalistic practice to include epidemiologic and statistical context whenever covering stories that focus on violence or dangerousness; base rates of violence in the relevant psychiatric group and general population should be provided so readers can see for themselves that the mentally ill pose little risk.

The press could stand to lose some of its lurid interest in psychiatric illness and see that good news is news, too. Stories of people with mental illness who succeed in life and contribute to society will actually be more surprising to the public than the typical psychotic-gunman-on-the-rampage feature, which it has come to expect -- not to mention the fact that positive stories can help explode negative stereotypes of the mentally ill. News stories that include the perspective of people with mental illness, their family members, and their advocates would be a welcome change. Media coverage of mental health has relied too heavily on a small cadre of experts, like psychiatrists, psychologists, and policy-makers. The virtual exclusion of the voices of mental-health consumers in the press gives the public the misleading impression that the mentally ill are too disturbed and dysfunctional to speak for themselves. Putting a human face on a psychiatric illness, as any social scientist can tell you, makes it easier for people to empathize and identify with those affected. It also helps to lessen stigma.

Public figures and celebrities who reveal their own experience with psychiatric illness or drug abuse show by example that one can thrive and achieve at the highest levels despite having a mental illness and that there is nothing to be ashamed of. A recent biography of Abraham Lincoln (Lincoln's Melancholy, by Joshua Wolf Shenk), for instance, argues that the president's lifelong depression was one source of his greatness. Speculation abounds over the role mental illness played in Vincent van Gogh's creative genius, of course. More recently, the Nobel Prize-winning economist John Forbes Nash (schizophrenia); writers William Styron (depression and alcoholism) and Art Buchwald (depression); actresses Brooke Shields (postpartum depression) and Patty Duke (bipolar disorder); TV journalists Mike Wallace (depression) and Jane Pauley (bipolar disorder); football great Herschel Walker (dissociative identity disorder); and public figures such as Betty Ford (alcohol and painkillers) and Tipper Gore (depression) have shared the private and public sides of their illnesses, as does Ted Sorensen, painfully recounting his mother?s manic depression in a new memoir. By following their lead and reporting on mental illness with candor and sensitivity, the news media and entertainment industry can dramatically dispel stigma and thereby do great social good.

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