Running Head: Portrayals of Mental Illnesses

1 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES Portrayals of Mental Illnesses in Women’s and Men’s Magazines in the United States

To appear in Journalism and Mass Communication Quarterly

Yiyi Yang, MA

College of Communication and Information Sciences

University of Alabama

Lu Tang, PhD

Department of Communication Studies

University of Alabama

Bijie Bie, PhD (Corresponding author)

University of Alabama 2

Abstract

Mental illness is a serious health risk in the United States. People suffering from mental illnesses are often subjective to gender-specific stigma and stereotypes. Based on theories of agenda setting, framing, and stigma communication, this study compares the portrayal of mental illnesses in women’s and men’s life style and health magazines between 2009 and

2013 through a content analysis. It finds that women’s magazines tend to present a more positive coverage of mental illnesses by citing patients, adopting human interest discourse, and using challenge cues such as hope than men’s magazines. Theoretical and practical implications are discussed.

Keywords: mental illness, magazines, gender, stigma 3 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES Portrayals of Mental Illnesses in Women’s and Men’s Magazines in the United States

Mental illness is a serious health risk and one of the leading causes of suicide and disabilities in the United States (Substance Abuse and Mental Health Services

Administration, 2014). Significant differences in the rate of several mental disorders exist between women and men: Women are more likely to suffer from depression, anxiety, and somatic complaints, while men are more likely to be diagnosed with antisocial personality disorders (World Health Organization, 2001). People with mental illnesses suffer from stigma and stereotypes (Klin & Lemish, 2008). Such stigma often has a gender bias such that men suffering from mental illnesses are often considered to be violent and dangerous, while women with mental illnesses are usually thought to be dependent and incompetent (Wirth &

Bodenhausen, 2009).

Mass media, such as TV, newspapers, and magazines, are a primary source of information on mental health and have a profound influence on public’s knowledge about and attitudes toward mental illnesses (Ray & Hinnant, 2009; Slopen, Watson, Gracia, & Corrigan,

2007). They also contribute to the stigmatization of mental illnesses by constructing and spreading misperceptions and stereotypes (Brodie, Foehr, Rideout, & Baer, 2001). People with mental illnesses are often represented as nuts, psycho, and crazy (Harper, 2005).

Furthermore, even though a small percentage of people with mental illnesses are connected to violent crimes, the news media are more likely to report such news in headlines (Harper,

2005; Klin & Lemish, 2008). Television dramas and films have also been found to depict people with mental illnesses as violent and unpredictable (Bryne, 2001). Even medical journals portray people with schizophrenia as violent in their advertisements (McKay, 2000).

Selective coverage of violent crimes committed by people with schizophrenia reinforces the stigma of mental illnesses as a whole (Angermeyer & Matschinger, 2003). 4

Mental illness stigma is gendered (e.g., Gardner, 2007; Harper, 2009); however, in- depth research on how the mass media contribute to the gendered stigma of mental illnesses still remains scant. This study examines how men’s and women’s magazines in the United

States cover mental illnesses. Magazines are a trusted source of general health information among both adults and adolescents (Hesse et al., 2005) and provide an ideal platform to study how mental illnesses are stigmatized (Ray & Hinnant, 2009). Theoretically, this paper provides a comprehensive framework to examine illness-specific stigma based on theories of agenda setting, framing, and stigma communication. Practically, it provides baseline data for health journalists and healthcare professionals to promote public awareness of mental illnesses and reduce stigma.

Literature Review

Gender Bias in Media Coverage of Health

Gender biases have been observed in mass media’s coverage of many health topics, including cancer (Andsager & Powers, 2001; Arrington & Goodier, 2004; Lantz & Booth,

1998), HIV/AIDS (Hoffman-Goetz, Friedman & Clarke, 2005; Myrick, 1999), menopause

(Kaufert & Lock, 1997), and medical research (Dingel & Sprague, 2010; Petersen, 1999).

Such biased media coverage further perpetuates traditional gender roles (Kline, 2006).

For instance, mass media’s portrayal of HIV/AIDs demonstrates gender biases.

Traditionally, the mass media described HIV/AIDS as a risk for gay men and downplayed its risks to women (Raheim, 1996). More recently, the mass media have been giving increasing attention to HIV/AIDS as a risk to women; however, they tend to portray women as lacking knowledge about HIV/AIDS. For instance, Myrick (1999) analyzed Center for Disease

Control’s public service announcements about HIV/AIDS and identified explicit gender biases: women were portrayed as less knowledgeable about HIV/AIDS than men, but were assigned more responsibility for the contraction of HIV/AIDS and were even depicted 5 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES visually as posing risks to men. Similarly, Hoffman-Goetz, Friedman, and Clark (2005) examined the coverage of HIV/AIDS in aboriginal newspapers in Canada and found these newspapers portrayed aboriginal women as at high risk, but lacking knowledge about the extent of the risk.

Cancer is another disease suffering from gender-biased media coverage. For instance, mass media have been found to portray breast cancer as a disease of individual persons, but depict prostate cancer as a couple’s disease. Women’s nontraditional behaviors, including smoking, drinking, and reproductive choices, were depicted as risk factors leading to breast cancer in popular magazines (Lantz & Booth, 1998). In contrast, Arrington and Goodier

(2004) found that NYPD Blue prime-time series portrayed prostate cancer as a couple’s disease characterized by couple’s joint involvement in coping with the psychological burden and making decisions about screening and treatment.

Moreover, gender bias was found in mass media’s coverage of genetic research.

Petersen (1999) studied the representations of genetic research in five popular science journals in the United States from 1980 to 1997, and found these magazines emphasized the genetic differences between men and women using sexist and heterosexist language and metaphors. For instance, phrases such as “lacking”, “left behind in the race”, and “missing the boat” were used to describe women (p. 176). In a more recent study of the coverage of genetic research on fetal sex development in newspapers and magazines, Dingel and Sprague

(2010) found that the inherent superiority of men was conveyed as a theme.

Gender and Mental Illness

Various risk factors contribute to mental illnesses, such as risk genes, substance abuse, and traumatic and stressful life experiences; however, the scientific community as a whole has not reached any consensus on the relative significance of these causes (Bulloch,

Lavorato, Williams, & Patten, 2012; Caspi et al., 2003; Purcell et al., 2009). Gender 6 differences have been found in the occurrence rate of high-prevalence disorders such as depression and anxiety (WHO, 2001), but not in low-prevalence disorders such as schizophrenia and bipolar disorder (Astbury, 2001). In the United States, most affective disorders and non-affective psychosis are more prevalent among women, while substance use disorders and antisocial personality disorders are more common among men (Brown,

Leonard, Saunders & Papasouliotis, 1998; Kessler, 2003). Furthermore, gender differences are also found in the timing of the onset of symptoms, persistency of certain disorders, course of disorders, and comorbidity (WHO, 2001). For instance, men with schizophrenia generally experience earlier onset of symptoms (Piccinelli & Homen, 1997), while women with bipolar disorder are more likely to develop the rapid cycling form of the illness (Leibenluft, 1996).

The diagnosis and treatment of mental illnesses often demonstrates gender biases. For instance, women are more likely to be diagnosed with depression than men with similar scores on standardized examinations (Stoppe, Sandholzer, Huppertz, Duwe & Staedt, 1999) and are more likely to be prescribed psychotropic medication (Simoni-Wastila, 2000). Such biases could lead to women receiving inappropriate medication and men getting inadequate treatment for depression (Bertakis et al., 2001). Media contribute to the gender biases about mental illnesses.

Media Coverage of Mental Illnesses

Historically the female body has been oppressed through social regulation and control

(Foucault, 1977). The development of modern medicine only intensifies such control (Hurt,

2007). On the contrary, men are expected to be independent, self-reliant, and invulnerable to environmental stressors (Addis & Cohane, 2005). Even mental illness stigma is gender specific: men tend to be considered violent and dangerous, while women are thought to be dependent and incompetent (Wirth & Bodenhausen, 2009). The gendered stigma of mental 7 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES illnesses leads to intensified discrimination: people are less sympathetic and less willing to help individuals with gender-typical mental illnesses (Wirth & Bodenhausen, 2009).

Mass media’s coverage of mental illnesses has been found to reflect traditional gender roles. First, media contribute to the pathologizing of the female body by emphasizing the biological differences of between the two sexes and constructing women as more susceptible to mental illnesses. Hurt (2007) analyzed the discourse of women and depression in contemporary news media and concluded that such a discourse constructed women as having

“defective bodies and passive minds,” and more susceptible to depression (p. 284). Gardner

(2007) found that public health campaigns about depression in the United States often emphasized sex-based biological causes of depression, which reinforced the gendered discourse surrounding women and depression. Brickman (2004) examined the portrayal of self-mutilation in medical journals and popular media and identified the image of a “delicate cutter,” typically that of a young white woman (p. 87). Sometimes media even blame women for men’s mental illnesses. For instance, Coyle and Morgan-Sykes (1998) analyzed the health section of a British broadsheet newspaper The Independent, and found that men suffering mental health crises were positioned as the victims of ambitious and sexually demanding women.

Gendered Coverage of Mental Illnesses in Men’s and Women’s Magazines

As a form of service journalism, gender-based life style and health magazines are an important source of health information. The rise of service journalism represents a shift in the purpose of news media from the provision of hard news to the provision of advices for audience in dealing with everyday problems (Eide & Knight, 1999). Service journalism is also called “smiling journalism,” emphasizing its differences from traditional journalism characterized with negativity (Hartley, 2000, p. 39). Hence, it is especially useful in promoting public’s knowledge about a variety of issues (Hartley, 2000). 8

Women’s magazines are a trusted source of information on health, lifestyle, and beauty for women (Len-Rios & Hinnant, 2014). Compared to newspaper and other mass media outlets, women’s magazines can be more easily integrated in their readers’ daily lives

(Hermes, 1995) and have powerful influence on women’s health beliefs and health behaviors.

For instance, the consumption of fashion and fitness magazines is linked to body image disturbance (e.g. Thomsen, 2002) and tanning intention (e.g. Dixon, Warne, Scully,

Wakefield, & Dobbinson, 2011). Similarly, men’s magazines have been found to reinforce traditional masculinity (Crawshaw, 2007). For instance, men’s magazines tend to fuel men’s pursuit of the ideal male body image characterized by leanness and muscularity (Law &

Labre, 2002).

Gender-role stereotypes are prevalent in women’s and men’s magazines. For instance,

Reicher, Morgan, Carstarphen, and Zavoina (1999) examined the advertisements in two news magazines (Time and Newsweek) and four service journalism magazines (Cosmopolitan,

Redbook, Esquire and Playboy) between 1983 and 1993 and found the number of sexual portrayals of women were three times higher than that of men. Lindner (2004) reported that women were consistently portrayed as subordinate to men in the advertisements in Vogue and

Time between 1955 and 2002. Because of this, one can expect that gendered stigma of mental illnesses intensively perpetuated in men’s and women’s magazines. Hence, the current paper seeks compare how men’s and women’s magazines in the U.S. cover mental illnesses through a content analysis guided by theories of agenda setting, framing, and stigma communication.

Agenda setting. Mass media can set public agenda by telling their audiences what the major mental illnesses afflicting the general population are by giving these illnesses extensive coverage (Scheufele, 1999). While most existing studies on agenda setting are based on newspapers and TV, magazines can influence the public agenda as well. Pratt, Ha, & Pratt,

(1992) found that magazines set the public health agenda in Sub-Saharan Africa by 9 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES emphasizing stigmatized diseases such as HIV/AIDS and deemphasizing non-stigmatized diseases such as Malaria and TB. In terms of the media agenda related to mental illnesses,

Slopen et al. (2007) found that newspapers paid most attention to antisocial behavior, depression, schizophrenia, and anxiety. Wahl (1992) reported that severe psychotic mental illnesses were most commonly presented in films. Currently, very little is known about the most frequently covered mental illnesses in men’s and women’s magazines. Hence the first research question (RQ) is proposed:

RQ1: What are the major mental illnesses covered in men’s and women’s magazines?

Framing. Mass media frame public’s perception about a certain issue by selectively highlighting some aspects and downplaying other aspects of it (Scheufele, 1999). Framing includes cause framing, source framing, and discourse framing, among others (Entman,

1993). Cause framing tells the audience what factors cause mental illnesses. Discussion of the causes of mental illnesses gives the audience a sense of security and optimism because if the cause of an illness is found, it can be understood, treated, and prevented (Conrad, 2001).

Furthermore, cause framing influences audiences’ attitudes and decisions: when an illness is attributed to factors beyond an individual’s control, the public is more likely to be sympathetic and willing to help (Jeong, 2007).

External and genetic causes of mental illnesses have been prominently featured in the media. Linsky (1970) reported that environmental and economic factors were the most often mentioned causes in magazines’ coverage of mental illnesses from 1900 to 1966. More recently, Clarke (2011) found that environmental and genetic causes were the two most frequently attributed causes for childhood depression in mass print magazines in the United

States and Canada. Slopen et al. (2007) reported that environmental factors and genetic/biological factors were found in 10.1% and 4.6% of newspaper articles about adult mental illness. Zhang, Jin, and Tang (2015) found Chinese newspapers were more likely to 10 attribute depression to societal causes than individual causes even though this trend became less obvious overtime.

Research shows that women and men tend to make different attributions of the causes of mental illnesses. For instance, men are more likely to attribute depression to individual responsibilities while women are more likely to attribute it to life stress or social variables

(Swords, Heary, & Hennessy, 2011). This is consistent with traditional gender roles that emphasize autonomy and self-reliance for men and interdependence and connection for women (Addis & Cohane, 2005). Hence, it is hypothesized that women’s magazines are more likely to make societal level attribution by blaming the society or environment, while men’s magazines tend to make individual level attributions citing biological or personal circumstances. This leads to H1a and H1b:

H1a: Women’s magazines are more likely to make societal level attributions in

discussing the causes of mental illnesses than men’s magazines.

H1b: Men’s magazines are more likely to make individual level attributions in

discussing the causes of mental illnesses than women’s magazines.

Next, an examination of the discourses (human interest discourse vs. scientific discourse) used in the portrayal of mental illnesses is due. Human interest discourse “brings a human face or an emotional angle to the presentation of an event, issue, or problem” and is more likely to trigger audiences’ interest (Semetko & Valkenburg, 2000, p. 95). In comparison, scientific discourse reflects the biomedical model of health and involves the use of logic, rationality, and data. It often leads to the impression of objectivity, credibility, and authority (Clarke, 2011). Although the scientific discourse provides valuable information about mental illnesses, relying solely on this discourse downplays the social and environmental factors that influence the daily experiences of people with mental illnesses

(Wahl, 2000). 11 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES Women’s magazines tend to embrace the human interest discourse in covering health issues. For instance, studies showed that women’s magazines in Australia and the United

States focused on the subjective experience of individuals and communities in covering breast cancer (Andsager & Powers, 1999; McKay & Bonner, 1999). The use of such a discourse acknowledges the personal nature of breast cancer and recognizes the emotions associated with the experience of breast cancer. The use of the human interest discourse is consistent with traditional feminine qualities, such as emotional expressiveness and self- disclosure (Burn, 1996). On the contrary, news media’s coverage of men’s health is characterized by the use of a scientific discourse, which reflects the traditional construction of masculinity by emphasizing logic and autonomy and suppressing the expression of emotions

(Lyon & Willott, 1999). Statistics and figures were employed to provide scientific information and to imply the objectivity of such information (Lyon & Willott, 1999). Hence, the next two hypotheses are proposed:

H2a: Women’s magazines are more likely to adopt the human interest discourse than

men’s magazines.

H2b: Men’s magazines are more likely to adopt the scientific discourse than

women’s magazines.

Source framing refers to the process by which the credibility and authority of an information source are constructed in the media and accepted by audiences (Entman, 1993).

Experts have been the most cited source in news media’s coverage of mental illnesses. For instance, Slopen et al. (2007) found that mental health experts were cited in 38.7% and 25.2% of the newspaper articles addressing adult and child/adolescent depression respectively in the

United States. Similarly, in studying the coverage of mental illnesses in the six most widely read newspapers and magazines in three Central European countries in 2007, Nawková et al.

(2012) found that mental health professionals were cited in one third of the articles. However, 12 the voices of patients suffering from mental illnesses were inadequately presented in the media. Nawková et al. (2012) found that only 10% of the articles quoted the opinions of people with mental illnesses. Similarly, Wahl (2000) reported that the voices of people with a mental disorder were limited in U.S. magazines from 1983 to 1997.

Understanding source framing in the media coverage of mental illnesses is important for several reasons. People have insufficient knowledge about mental illnesses, which creates the need for credible information (Ray & Hinnant, 2009). The prominence of expert voices, such as those of medical professionals and researchers, suggests that these types of sources are deemed qualified to speak about this topic (Rowe, Tilbury, Rapley & O’Ferrall, 2003).

The silence of people suffering from mental illnesses can lead to the further stigmatization of this population.

Since citing non-expert sources such as patients, family, and friends are associated with the human interest discourse and citing expert sources such as doctors and researchers are associated with the use of the scientific discourse, it is hypothesized that women’s magazines are more likely to use non-expert sources while men’s magazines tend to cite expert sources more frequently.

H3a: Women’s magazines are more likely to cite non-expert sources than men’s

magazines.

H3b: Men’s magazines are more likely to cite expert sources than women’s

magazines.

Stigma Communication. Stigma is defined as a mark associated with disgrace or discredit (Goffman, 1963). Such a mark excludes the affected person from a community both socially and physically (Bryne, 2001). According to Smith (2007), illnesses can be depicted through a stigma format or a challenge format. Stigma communication highlights qualities that stimulate categorization, avoidance, feelings of threat, and reminders of self-protection 13 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES with the intention to guard against the perceived danger (Smith, 2007). Stigma cues include marks (external characters), social exclusion (e.g., using they-language), responsibility (e.g., implying that those who are stigmatized chose their stigmatized condition), labeling (e.g., using labels affixed by communities which stress that the stigmatized group is a separate social entity), and peril (e.g., propagating the notion that a stigmatized group poses a threat to the rest of the community) (Smith, 2007). On the contrary, messages cultivating positive attitudes toward mental illnesses are considered challenge communication (Smith, 2007).

Challenge cues include optimism (e.g., showing people smiling or relaying other positive messages), hope (e.g., emphasizing success in dealing with an illness), social inclusion (e.g., using us-language), personification of the health concern (e.g., placing the illness as the subject or direct object of a sentence, such as “Cancer kills”), and combat (e.g., portraying patients who fight their condition) (Smith, 2007). Examining the stigma and challenge cues used in the media coverage of mental illnesses will provide insights into the extent to which such coverage might lead to a positive or a negative impression of people suffering from these conditions.

Women have been found to be more accepting of people with mental illnesses, less likely to endorse stigma when discriminatory behaviors are invoked, and more likely to offer help to people with mental illnesses than men (Corrigan, Powell, & Michaels, 2013). As a result, H4a and H4b are proposed based on the assumption that the gender-based attitudinal differences toward mental illnesses will be reflected in women’s and men’s magazines.

H4a: Men’s magazines are more likely to use stigma cues than women’s magazines in

the portrayal of mental illnesses.

H4b: Women’s magazines are more likely to use challenge cues than men’s

magazines in the portrayal of mental illnesses.

Method 14

Sampling and Unit of Analysis

Ten highly circulated health and life style magazines published in the United States were selected. Among the five women’s magazines, Vogue, Cosmopolitan, and Marie Claire are fashion and lifestyle magazines, and Shape and Self are health and fitness magazines.

Among the five men’s magazines, GQ, Esquire, and Details are fashion and lifestyle magazines, and Men’s Health and Men’s Fitness are health and fitness magazines. (See Table

1 for the circulation numbers of these magazines.)

------Insert Table 1 about here ------

Three types of key words were used. The first type included general terms related to mental illness (e.g. mental and psycho-) (Francis et al., 2004; Nawková et al., 2012). Terms associated with specific mental health issues were also included (e.g., depression, schizo-, anxiety) (Francis et al., 2004). Finally, the term stress was also used, as it was perceived to be one of the most decisive causes of mental illnesses (Link et al., 1999). The current study included articles published between 2009 and 2013 with the goal of providing an up-to-date description of magazines’ portrayal of mental illnesses. A search of these magazines’ archival databases using the keywords mentioned above within our time frame yielded 3,431 articles.

However, most of these articles only mentioned mental illnesses in a marginal manner. Since the goal of this study was to investigate how mental illnesses were portrayed in magazines, only articles focusing on mental illnesses were retained for analysis. Two coders conducted two rounds of screening. In the first round, two coders randomly selected 50 articles from both men’s and women’s magazines, coded whether these articles should be included in the final sample, and discussed their discrepancies. Next they screened another 500 randomly selected articles and achieved a Cohen’s Kappa (κ) of .798. They then split the rest of the articles and screened them separately. In the end, the current study included 193 articles for 15 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES further coding and data analysis. Examples of articles excluded from the data analysis included pieces discussing how stress could lead to skin breakouts or articles about the economic depression.

Codebook, Coding, and Intercoder Reliability

Each article in the final sample was coded for the following dimensions: demographic information, types of mental illnesses, cause, discourse type, source cited, and message cue.

First, the demographic information of each article was coded, including the article’s ID, magazine, and date of publication. Second, six types of mental health topics were coded: depression, anxiety, stress, PTSD, mental illness in general, and others.

Cause framing was coded based on the categories developed by Angermeyer and

Matschinger (2003), including biological factors (e.g., brain disease), psychosocial stress

(e.g., difficulties in work or family relationships), socialization (e.g., lack of parental affection), intrapsychic factors (e.g., lack of willpower), and society (e.g., loss of traditional values). Biological, psychosocial, socialization, and intrapsychic causes were then combined to represent individual level causes.

Next, discourse type was coded based on the framework developed by Ray and

Hinnant (2009). Human interest discourse was coded when an article included narratives or profiles of people with mental illnesses or those who knew someone suffering from mental illnesses. Scientific discourse was coded when an article included concise scientific information, such as citing statistics and research studies, about a mental health issue instead of embedding the information in narratives.

In order to investigate the source framing used, each article was coded based on sources cited in terms of two main categories: non-expert resources (family, patient/self, friends, and acquaintances) and expert resources (non-profit organizations with a mental illness focus, governmental agencies, doctors, and researchers). 16

Finally, each article was also coded for the challenge and stigma cues used based on the theoretical framework of Smith (2007). First, we coded those challenge cues most relevant to mental illnesses: hope, social inclusion, and combat. Hope referred to messages emphasizing success in overcoming mental illnesses. For instance, “I’ve learned to deal with my depression and feel more in control. Finally, I think I can say that I’m happy.” Social inclusion was coded when the article accentuated the integration of the stigmatized groups into society in general, for example, when the article used “us” language. Combat was coded when the article highlighted cases where people fought their mental illnesses. For example,

“Sometimes, in lighter moments, I imagine myself as an intergalactic fighter, valiantly armed with my pills, determined not to surrender to an enemy most people can’t even make out.”

Stigma cues, including marks, social exclusion, responsibility, peril, and labeling, were coded (Smith, 2007). Mark was coded when an article described the characteristics that distinguish people with mental illnesses, such as unpredictable or suicidal behaviors. For instance, “I grabbed a bottle of pills and threatened to take them. I threw myself on the floor at the mercy of the hospital director, pleading and crying for him to let me out.” Social exclusion was coded when the article depicted people with mental illness as an isolated and marginalized group. One example was “us versus them” language, such as “those people” or

“those PTSD guys”. Responsibility was coded when the article stated that those suffering from mental illnesses should be blamed for their condition. Peril was coded when an article expressed concerns about the dangers posed by the mentally ill. One example of peril was:

“During the worst of it, Bryant would drink to black out and vanish for days or weeks on end.” Labeling was coded when an article used labeling terms (such as the mentally ill, maniac, crazy, etc.) to describe those suffering from mental illnesses as a whole.

Two coders coded all 193 articles in the sample to ensure intercoder reliability, and

Cohen’s Kappa was calculated for each variable. They reached an overall κ of .938 (.93 for 17 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES major topics covered, .99 for cause framing, .97 for source framing, .99 for discourse type, .

81 for challenge cues, and .94 for stigma cues). They reviewed and resolved the differences.

Results

Among the 193 articles coded, 52.8% (n = 102) were found in women’s magazines and 47.2% (n = 91) in men’s magazines. (See Table 1 for the distribution of these articles in each magazine.) Chi-square tests were run to compare the portrayal of mental illnesses in women’s and men’s magazines. Holm’s sequential Bonferroni correction was conducted to adjust the p value for multiple testing (Abdi, 2010). Overall significant differences were found in source framing, discourse type, and challenge cues.

RQ1 sought to determine the major mental health topics covered in men’s and women’s magazines. Overall, depression (40.9%, n = 79) and stress (40.4%, n = 78) were the most prominent topics, followed by anxiety (30.1%, n = 58), other mental health issues

(13%, n = 25), mental illness in general (6.7%, n = 13), and PTSD (6.2%, n = 12). In women’s magazines, the most prominent topic related to mental health issues was depression

(44.1%, n = 45), followed by anxiety (34.3%, n = 35), stress (33.3%, n = 34), other mental illnesses (13.7%, n = 14), mental illness in general (6.9%, n = 7), and PTSD (3.0%, n = 3). In men’s magazines, stress (48.4%, n = 44) was the most covered topic, followed by depression

(37.4%, n = 34), anxiety (25.3%, n = 23), other mental illnesses (12.1%, n = 11), PTSD

(10.0%, n = 9), and mental illness in general (6.6%, n = 6). However, the differences between men’s and women’s magazines were not statistically significant.

H1a and H1b examined the cause framing in men’s and women’s magazines’ coverage of mental illnesses. Data indicated that 45.1% of the articles (n = 46) in women’s magazines and 36.2% of the articles (n = 33) in men’s magazines discussed the causes of mental illnesses. Overall, individual causes were more likely to be cited (n =116) than social causes (n = 8) in both men’s and women’s magazines. However, no significant differences 18 were found between women’s and men’s magazines in their likelihood of citing either social or individual causes of mental illnesses. Thus, H1a and H1b were not supported. To further investigate the differences in cause framing, comparisons were made between the mention of following individual level causes: biological cause, psychosocial cause, socialization, intrapsychic, but no significant difference was found in any of these causes. In both men’s and women’s of magazines, psychosocial stress was the most prominent cause discussed followed by biological causes, society, and socialization.

H2a and H2b examined the types of discourses used. Human interest discourse and scientific discourse were found in 22.3% (n = 43) and 28.0% (n = 54) of all articles in the sample. Women’s magazines were significantly more likely to employ the human interest discourse than men’s magazines, (1, N = 193) = 6.355, p = .012, adjusted p = .024; however, there was no significant difference in the use of scientific discourse in men’s and women’s magazines. As a result, H2a was supported, but H2b was not supported.

H3a and H3b investigated source framing in magazines’ coverage of mental illnesses.

Overall, 90% of the articles studied (n = 173) cited at least a source. Expert sources were cited more often than nonexpert sources, with 75.5% of articles in women’s magazines and

72.5% of articles in men’s magazines cited expert sources. Women’s magazines were more likely to cite non-expert sources (including patients, family members, friends, and other non- expert sources) than men’s magazines, (1, N = 193) = 5.158, p = .023, adjusted p = .046. A set of follow up tests showed that women’s magazines were significantly more likely to cite patients than men’s magazines, (1, N = 193) = 6.464, p = .011, adjusted p = .044. However, no significant difference was found in the use of expert sources overall or each individual type of expert sources (including non-profit organizations, government, doctors, and researchers) between men’s and women’s magazines. Thus, H3a was supported, but H3b was not. 19 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES H4a and H4b examined the use of challenge and stigma cues in women’s and men’s magazines’ coverage of mental illnesses. Overall, challenge cues were found in 33.7% of all articles (n = 65), while stigma cues were only found in 14.0% of all articles (n = 27).

Women’s magazines were more likely to use challenge cues than men’s magazines, (1, N =

193) = 5.445, p = .020, adjusted p = .040. A set of follow-up tests indicated that women’s magazines were more likely to use the cue of hope, (1, N = 193) = 18.483, p = .000, adjusted p = .000. Next, men’s magazines (n = 14, 15.4%) were somewhat more likely to use stigma cues than women’s magazines (n = 13, 12.7%), but the difference was not statistically significant. Hence, H4a was supported, but H4b was not.

Discussion

Answering the calls of Anderson and Bresnahan (2013) and Weiss, Ramakrishna, and

Somma (2006) to explore the gender and cultural dimensions of illness-specific stigma, the current article examines the representation of mental illnesses in women’s and men’s health and lifestyle magazines in the United States, focusing on mental health topics, cause framing, discourse type, source framing, and the use of challenge and stigma cues. Overall, women’s magazines are more likely than men’s magazines to employ the human interest discourse, to cite non-expert sources, and to adopt challenge cues such as hope.

In terms of major topics covered, both women’s and men’s magazines paid most attention to depression, stress, and anxiety, which is consistent with the findings of previous research on media coverage of mental illnesses (e.g., Slopen et al., 2007). This finding is also consistent with the prevalence of anxiety and depressive disorders recorded in the United

States (Kessler, 2003).

Concerning cause framing, more than half of the mental illness-related magazine articles did not include any reference to causes. Both men’s and women’s magazines were more likely attribute mental health issues to individual causes rather than social causes. This 20 finding is consistent with the tendency to stress personal responsibilities and embraces personal control over one’s body and health (Brownell, 1991). To some extent, the mention of individual causes implies individual responsibilities for mental health, which could trigger stigmatizing attitudes and decrease helping behavior (Weiner, 1995). Moreover, the emphasis on individual causes could also encourage a self-help approach in mental illness treatment and overstate an individual’s control over his or her health.

Women’s magazines are more likely to use the human interest discourse than men’s magazines. The human interest discourse “brings a human face” to a health issue (Semetko &

Valkenburg, 2000, p. 95). The experiences of patients, families, and friends underscore the importance of socio-cultural contexts and are likely to influence social support options and coping strategies. Moreover, the human interest discourse employed in women’s magazines could potentially reject the disciplining of the female body and create a sense of community and relationship, rather than isolation and marginalization, to the discourse of women’s mental illnesses.

In terms of source framing, women’s magazines are significantly more likely to cite non-expert sources, especially people with mental illnesses, than men’s magazines. As magazines are often more leisure-oriented and opinion-based (Harper, 2005), first-person narratives that allow people with mental illnesses to talk about their experiences are expected to be frequently used in magazines. The vivid narratives of women’s mental illness experiences could serve as a critical tool to understand the factors that influence women's mental health beliefs and could provide implications for women’s mental health promotion.

However, an overuse of such personal stories may also create the impression that mental illnesses are more prevalent among women than they actually are and contribute to the

“women in crisis” illusion (Meyer, Fallah, & Wood, 2011, p. 216). 21 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES Finally, based on stigma communication theory, the current study examined the use of challenge and stigma cues in women’s and men’s magazines’ coverage of mental illnesses.

Overall, challenge cues are used more than stigma cues. This encouraging finding is consistent with the idea that magazines as a form of service journalism and are likely to provide a more positive description of mental illnesses. It demonstrates the potential of magazines to promote the de-stigmatization of mental illnesses. Further investigation of the challenge cues used indicates that women’s magazines often use the cue of hope. Previous studies have found that messages highlighting positive treatment outcomes can effectively reduce stereotypes and prejudices about mental illnesses (Corrigan, Powell, & Michaels,

2013; Romer & Bock, 2008). In comparison, only 4.4% of articles in men’s magazines contained hope cues, suggesting that there is an urgent need to overcome traditional gendered prejudice against men with mental illnesses. Furthermore, the considerable lack of optimism, social inclusion, and combat cues in both women’s and men’s magazines might contribute to a sense of desperation and isolation. Public health professionals and health journalists should promote more positive media messages that contain these challenge cues in order to reduce mental illness-related stigma for both men and women.

Limitations and Directions for Future Research

The current study has several limitations. Although sampling of 10 different magazines over a 5-year period yielded 3,431 articles initially, only 193 of them focused on mental illnesses. The overall small sample size is consistent with the idea that mental illness has long been a cultural taboo in the United States (Szasz, 2003). It also limits the generalizability of this study’s findings. Next, the magazines used in this study were selected purposefully based on their foci and circulation. These magazines might have less rigorous editorial standards than daily newspapers or news magazines. Hence, the findings of this study may not be generalizable to the mental health portrayals within other types of news 22 media. Furthermore, the period studied (2009-2013) witnessed a few mass shooting incidents extensively covered in the news such as Fort Hood shooting in 2009, Seal Beach shooting in

2011, Sandy Hook Elementary School shooting in 2012. These incidents might confound the findings of the study by increasing magazines’ coverage of mental illnesses. Our data tentatively suggest that these incidents did not increate magazines’ coverage of mental illnesses as number of articles steadily decreases over the years. However, it is still possible that these incidents might have influenced the ways in which mental illnesses are covered in women’s and men’s magazines.

Conclusions

This study provides an overview of the portrayal of mental illnesses in women’s and men’s magazines in the United States between 2009 and 2013. It reaches a few encouraging conclusions: women’s magazines appear to be more open to talk about mental illnesses by citing more non-expert sources and employing more human interest information; and overall, more articles are depicting mental illness in a challenge format rather than in a stigma format.

However, some areas that remain problematic are the overemphasis of individual causes of mental illnesses, the “women in crisis” illusion, and the lack of challenge cues in men’s magazines.

Theoretically, this study provides a fresh path in assessing the mediated portrayal of mental illnesses by incorporating the perspectives of gender and stigma communication into the theories of framing and agenda setting. Theories of agenda setting and framing provide a guidance to the analysis of media content on mental illnesses in terms of topics covered, causes discussed, discourses used, and sources cited. Theory of stigma communication allows researchers to focus on language choices in the media content. Our findings show that all three theories are useful in guiding an analysis of gendered coverage of mental illnesses in magazines and potentially in other media outlets. This new approach is a major contribution 23 RUNNING HEAD: PORTRAYALS OF MENTAL ILLNESSES of the current study. Continued investigation based on this theoretical approach will provide insights into the gendered portrayal of mental illness and other health issues in mass media.

Findings of this study also suggest several courses of action for public health professionals and health journalists, especially service journalism magazines. For instance, treatment outcomes, optimism, social inclusion, and information on combating mental illnesses should be taken into account when designing future media campaigns. 24

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Magazine Circulation1 Frequency Valid Percent (%) Women’s Magazines 102 52.8 Vogue 1,229,880 14 7.3 Cosmopolitan 3,019,778 8 4.1 Marie Claire 974,950 14 7.3 Shape 1,638,925 39 38.2 Self 1,515,880 27 14.0 Men’s Magazines 91 47.2 GQ 943,676 11 5.7 Esquire 746,556 14 7.3 Details 524,791 7 3.6 Men’s Health 1,839,433 42 21.8 Men’s Fitness 627,352 17 8.8

1 The circulation numbers of these magazines are based on the data reported by Alliance for Audited Media (2014), retrieved April 2015 from http://abcas3.auditedmedia.com/ecirc/magform.asp.