An Exploratory Analysis of the Portrayal of Mental Illness in Qatar’s Newspapers

Background

According to the World Health Organization (WHO), mental disorders comprise a broad range of problems with different symptoms that are generally characterized by some combination of abnormal thoughts, emotions, behavior and relationships with others.¹ Recent worldwide reports suggest that mental and addictive disorders affect more than one billion people globally, with depression causing most disability.² Unfortunately, many people do not recognize the symptoms associated with mental disorders and consequently do not access treatment.³ It has been suggested that nearly two-thirds of people with a known mental disorder never seek help from a health professional.⁴ Although this may be multifactorial, evidence suggests that stigma, discrimination and neglect prevent care and treatment from reaching people with mental illness.^2,3 Several studies have demonstrated that media often presents people with mental illness negatively, linking them with acts of violence, crime, dangerousness and disability, promoting public stigma.⁵

In the mental health context, public stigma occurs when members of the general public endorse stereotypes about mental illness and act on the basis of these stereotypes. It refers to a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid and discriminate against the mental ill.⁶ As a result of mental health stigma, the service and treatment gaps for an already underserved population widen, leaving individuals with mental illness having to cope not only with the burden and disability associated with their symptoms but also with the societal stigmatization of their illness.^7,8 Relatively recent reports suggest that stigma toward people with mental illness exists to a substantial extent among Arabs in the Middle East.^9,10

Qatar has a comparable prevalence of mental illnesses to those in other countries worldwide. According to Qatar’s Ministry of Public Health (MOPH), approximately one in five people in Qatar is estimated to be affected by mental illness at any given point in time.¹¹ Studies conducted on Qatar’s population to assess their knowledge, attitudes and behaviors towards mental illness are indicative that most people have poor mental health literacy, insufficient information about the causes and symptoms of mental illness, and stigmatized perceptions towards people with mental illness.^12–14 Thus, in order to reduce stigma and encourage access to mental health services, the provision of accurate information about mental illness and its treatment is crucial. Qatar’s MOPH identifies the media as a key vehicle to achieve their goals in relation to improving the population’s mental health literacy.¹¹ Responsible media can be an important ally in increasing the public’s knowledge, especially on poorly understood mental health topics. As a result, many countries have engaged public health specialists with media professionals in awareness campaigns to ensure destigmatized coverage about mental health is provided.^15,16

There has been limited information on the portrayal of mental illness in the Qatar media. Elzamzamy and colleagues recently reported an overview of the extent, nature and quality of reporting on mental health compared with physical health in Qatari newspapers.¹⁷ Although the study only examined articles published in a 2-month period, the results pointed to an overall under-representation of mental health in Qatari newspapers. In addition, the study did not examine coverage of mental health treatments. In this article, we present the results of a similar study, which provides additional information on the portrayal of mental health in English and Arabic Qatari newspapers after a year-round retrospective quantitative and qualitative content analysis.

Methods

A retrospective quantitative and qualitative content analysis approach of textual data published in Qatari newspapers between January and December of 2017 was used. Quantitative descriptive analysis was employed to determine the extent of media coverage while qualitative content analysis was employed to examine the discourse tone and assess the stigmatization of the main messages on the text.

Publication Selection

Two Arabic and two English daily newspapers with the highest circulation and reputation were selected to compare mental health coverage between Arabic and English newspapers and to ensure broader extraction of articles. The chosen Arabic newspapers were Al-Raya (circulation: 25,000/day) and Al-Watan (circulation: 13,600/day), whilst English newspapers were Gulf-Times (circulation: 22,000/day) and Qatar Tribune (circulation: 15,000/day). The electronic archives were used for article screening from Gulf Times and Al-Raya newspapers as PDF files, while for Qatar Tribune and Al-Watan, printed newspaper copies were used.

Inclusion/Exclusion Criteria

Articles were included if they reported about mental health generally and/or about specific mental disorders. The National Alliance on Mental Illness (NAMI) classification was used for defining mental health disorders which include anxiety disorders, attention deficit hyperactivity disorder, autism, bipolar disorder, borderline personality disorder, depression, dissociative disorder, psychosis, eating disorders, obsessive-compulsive disorders, post-traumatic disorder, schizophrenia, suicide and self-harm.¹⁸ Articles were included if mental health/illness was either a central or a subordinate theme of the article.

Only the “main” and “supplement” sections of newspapers were included in the screening process. There was neither a restriction of the article’s size nor the word count. The exclusion criteria were “sports” and “business” sections of the newspapers, advertisements, wedding announcements, obituaries, repeated news in the same newspaper, articles that talks about physical and mental disability together and metaphorically used mental illness-related words.

Search Strategy

The research was conducted in 2018, but daily newspapers from the previous year (2017) were included in the search. Screening for eligible articles that mention mental health-related topics was done by two investigators (SE and WO). For printed newspaper copies, article titles were screened manually, whereas keywords were used for searching the electronic copies. The search terms used included “mental”, “psych”, “autis”, “depress”, “ADHD”, “schizo”, “anxi”, “bipolar”, “eating”, “trauma”, “drug” and “treat”. The same terms were translated into Arabic for electronic Arabic newspapers.

Analysis

Data extraction sheets (for both languages) were developed and coded articles in three main categories. First, article identification (4 items) where articles were coded for their newspaper origin, date, and section of the newspaper (main or supplement). Second, level of attractiveness and interest given to mental health topics (8 items) based on previously established criteria, including the article location, the length of the article, the heading font size and color, distinction in article formatting, and the display of images if present.¹⁹ Third, content analysis of the article title and text (8 items) to extract the main theme or idea conveyed and the overall impression about the portrayal of mental illness was based on a modified version of a coding schema that was used in a similar study which explored newspaper depictions of mental and physical health.²⁰ In addition, articles were also analyzed for their types (news, events, educational, etc.), the source of the news (national or international), specified mental illness and treatment, and if they included a quotation and its source.

The data extraction sheets were built using SurveyMonkey^® (Survey Monkey Inc., San Mateo, California, USA) and piloted prior to being used. They were filled independently by two investigators (SE and WO). Counts and frequencies were determined for each item. To maintain consistency, the research investigators were trained for the intended meaning of each item and the definition of each option before the actual study conduction. Any uncertainty in filling the data collection sheet was further resolved by consensus with a third investigator (MZ).

To assess if there were any differences in the extent of mental health coverage compared with a similarly highly prevalent physical condition in Qatar, such as diabetes mellitus (DM), the Qatar-Tribune newspaper was screened over a one-year period. It has been reported that the prevalence of DM in the Qatari adult population is approximately 17%.²¹ This incidence is similar to the prevalence of mental health disorders in Qatar (approximately 20%).¹¹ Qatar Tribune was the only newspaper that had a full availability of issues at the time of conducting the comparison. The search strategy applied for mental health topics was followed for diabetes-related article screening and data extraction. The included articles were surveyed using the pre-developed data extraction sheet after modification for the purpose of diabetes content analysis.

Ethical Approval

Ethics approval for the conduct of the study was not required as the data were obtained from an open source (newspapers published in public domains).

Results

A total of 659 articles were retrieved from the selected newspapers, 310 were found in English newspapers (Gulf Times n=183 and Qatar-Tribune n=127) and 349 in Arabic newspapers (Al Raya n=247 and Al Watan n=102). The average number of articles per month was 55. The months of April and October had the highest mental health-related coverage. The majority of the articles were published in the main section of the newspaper, although almost a quarter of articles in English newspapers were found in the supplement section.

Presence of mental health articles in the first or last pages was less than 10% in both language newspapers, and only around 20% of the articles occupied more than half of the page. Although the majority of the articles were small in size, large font size were used in the headlines. However, most headlines in both language newspapers were printed in black ink. About half of the articles in Arabic newspapers were displayed in a special format such as bordered or colored background. Almost two-thirds of articles in both language newspapers included images, mostly were of large size. In the majority of articles, the images provided a neutral impression.

The majority (44%) of mental health articles retrieved were in relation to general news. National news were mostly found in Arabic newspapers; whereas both, national and international news, were equally reported in English newspapers. Informative reports were published frequently on both language newspapers with themes such as “causes” and “symptoms” predominating. Only a few articles presented opinions of the general public or stories of people with mental illness and/or their families, and these were mostly published in English newspapers.

More than half of the articles from both language newspapers reported on a specific mental disorder such as autism spectrum disorder, depression, and anxiety disorders. Other disorders like schizophrenia, bipolar disorder, eating disorder, attention deficit hyperactivity disorder, post-traumatic stress disorder, obsessive-compulsive disorder, and personality disorder had minimal coverage. A relatively large proportion of articles retrieved from both language newspapers were about treatments, the focus of these articles was mainly on non-pharmacological therapies. There was limited coverage in relation to religious or spiritual healing on both language newspapers.

The majority of articles in both English and Arabic newspapers used quotations to support mental health-related topics. The majority of these were quotes from experts in the field of mental health, while only a few were from people with mental illness or their families. The majority of articles (65%) displayed a neutral and non-stigmatizing portrayal of mental illness and its treatments. A more detailed description of the mental health coverage in English and Arabic newspapers is presented in Table 1.

Table 1 Mental Health Coverage in English and Arabic Newspapers

Comparison of Mental Health/Illness Coverage with Diabetes

Of the 179 articles extracted from Qatar Tribune over the 12-month period, 127 were related to mental health and 52 to DM, with an average number of 11 and 4 articles per month, respectively. Coverage of mental health topics remained highest in the month of April, whereas November was the highest for DM. The overall level of attractiveness of the articles covering mental health and DM topics was similar. The majority of the published articles on DM were informative reports, whereas mental health coverage was mostly related to general news. Event-related articles were more about DM than about mental health. Although mental health articles had more general treatment-related content, articles about DM emphasized on the side effects of medications. Both, mental health and DM articles displayed a similar written discourse tone, which was assessed mostly as being neutral (75.6% of mental health articles versus 65.4% of DM articles). A more detailed comparison between the newspaper coverage of mental illness and DM is presented in Table 2.

Table 2 Mental Health versus Diabetes Mellitus Coverage in the Qatar Tribune

Discussion

The key finding of this study, which systematically reviewed mental health coverage in Qatari newspapers for a period of one year, revealed a predominance of general news, with a written discourse tone considered as neutral and non-stigmatizing, except for non-national news that often linked mental illness with dangerousness or violence. In a recently published study by Elzamzamy and colleagues, who reviewed Qatari newspaper articles in a two-month period one year after, similar results were reported.¹⁷ In their study, they also reported the majority of the articles provided general mental health information and were either positive or neutral in tone. However, and in contrast to our findings, the study by Elzamzamy and colleagues also found almost three times more articles reporting on physical health than about mental illness. As our review only included DM, it is difficult to ascertain that their findings are truly different than ours, considering the wide range of possible physical illnesses that were covered in their review. Together, these findings are indicative that there appears to be a progressive intent in the Qatar media to increase mental health coverage and to portray mental illness less negatively than what has been previously reported in other countries around the world.^22–24

Several issues were analyzed which may further explain the above key findings. First, that in Qatar, newspaper reporting on mental illness is influenced by current worldwide events. This study results indicate that mental health content was more prominent in the months of April and October. This was likely linked to external events such as the “World Autism Day” and the “World Mental Health Day” which every year are scheduled in the months of April and October, respectively. Mental health coverage was notably lower in the month of June, most likely due to an important political event that occurred in Qatar in June 2017; specifically, the economic blockade imposed on Qatar by other Arabian Gulf countries. The higher number of articles about autism and depression that were found in this review was also possibly linked to important mental health-related events that were launched in 2017, the year this study was conducted, including the Qatar National Autism Plan and the World Mental Health Day campaign “Depression: Let’s talk”. However, little attention was given to other conditions that are often misunderstood and stigmatized, such as schizophrenia. Several studies have demonstrated a contribution of the media in the stigmatization and the negative perceptions surrounding schizophrenia.^25–28

Second, that general news in relation to mental health are the most frequent type of articles reported in Qatar’s newspapers. Although the majority of general news in this study were in relation to mental health events or campaigns happening in the community, and thus, carrying a neutral tone, non-local news related to mental health often provided negative portrayals of mental illness, such as associations between mental disorders with violence and crime. In addition, the size of some news articles about violence and crime related to mental illness were larger and occupying more than half of a page. Although these articles did not describe local news, this negative media coverage can contribute to the rejection, discrimination, and stigmatization of people with mental illness. Similar findings have been reported in other studies in the Arabian Gulf region.^17,29

Third, that there is a tendency to favor attractiveness in the headlines, rather than providing informative content about mental illness. Using images that have an eye-catching effect has been reported to positively support the readability and perception of the content in written media.¹⁹ Although images were included in the majority of the mental health-related articles, these were mostly photographs, logos, or advertisements of events, which overall, did not provide a meaningful connection to the content of the articles. It has also been suggested that the position of where the mental health article is placed in the newspaper is an indicator of how important is the topic of mental health for the media.³⁰ The majority of the mental health articles in this study were not located in the first or last pages, and even those that were on the first page, were mostly related to advertisements of upcoming events or about the provision of mental health services.

Other important findings in this study worth highlighting is that almost one-third of articles covered mental health treatments. In a similar Australian study, only around three percent of articles in three different daily newspapers covered this topic.³⁰ Our content analysis of the articles covering mental health treatments revealed that these focused mostly on non-pharmacological (natural or alternative) therapies rather than on medications. There was also low coverage about religious or spiritual healing as mental health treatments. This was an interesting finding, considering that previous studies conducted in the general population in Qatar reported that around 40% believed on spiritual healers to treat mental illness.^12,13 Results of a study in Saudi Arabia also reported less coverage about spiritual approaches as compared to new psychological and pharmacological treatments.²⁹

The majority of the newspaper articles included quotations derived from experts in the field of mental health. This strategy in reporting suggests an intent to demonstrate responsible journalism practices as well as providing some degree of reliability and trustworthiness to the information published. However, quotations from people with a mental health condition or their families were rarely included in these articles. Previous studies have also shown an overall under-representation of opinions from those experiencing mental illness.^24,31 Studies in Qatar have shown that the general public possesses misconceptions and non-optimal attitudes towards people with a mental health condition.^12,13 Including the perspectives of people with mental illness into media reports, “humanizes” mental illness by emphasizing it is real, common, and treatable.^31,32

Strengths and Limitations

Several points of strength support the quality of this study. First, we selected Qatari newspapers that have high visibility and readability. As such, all papers were first hand-searched according to the set criteria and complemented by electronic keyword searching, potentially increasing the yield of articles. Two investigators independently performed the search and rated the articles, and findings discussed with a third investigator to resolve any uncertainties. This strengthened the validity of the findings by triangulation.

This study has some limitations. First, the year in which the study was conducted (2017) could have generated unintentional bias in retrieving more positive mental health articles as it coincided with important awareness campaigns in relation to mental health. In addition, this study focused on newspapers and did not assess television or radio representations of mental illness. Lastly, the coding schema used to assess the portrayal of mental illness was not validated, although it was derived from other studies which used similar methodologies.²⁰

Conclusions

Four reputable English and Arabic newspapers were reviewed for their coverage of mental health topics and its treatments over one-year period. Analysis of the retrieved articles revealed a predominantly informative content, with mostly a neutral and non-stigmatizing tone except for non-national news that often linked mental illness with dangerousness or violence. Although overall encouraging findings, there is a need to: 1) increase representation of people with mental illness in print media, 2) increase awareness and scientific reporting on the diversity of treatments available (particularly medications), and 3) collaborate with the media to improve reporting to raise awareness of highly stigmatized mental health conditions such as schizophrenia.