An exploratory study on the 10-year dynamic changes of mental health policy development and media stigma reporting in China (2011

Abstract

Background:

China has introduced a large number of national mental health policies over the past decade. However, few studies have touched on what changes the policies brought to the media.

Aims:

This study aimed to investigate the relationship between stigma reports, classifications of mental disorders (SMI: severe mental illness vs. CMD: common mental disorders) and sources of information (mental health professionals vs. non-mental health professionals) from 2011 to 2020 in China Daily, an established official media of China.

Method:

This study consists of policy review and media review. The policy review reviewed the media management content in Chinese national plans, policies, and laws on mental health from 2011 to 2020. China Daily news articles reporting mental illness-related topics were included in this study as the media material. After a two-step review, the eligible news articles were coded with a structured codebook. The proportion and frequency of stigma depiction of mental disorders, classifications of mental disorders and source of information were counted by year. Chi-test was undertaken to determine the relationship between stigma reports and different classifications of mental disorders and sources of information. An exploratory analysis was conducted to explore the changes in depiction around time points of policy publications.

Results:

The number of anti-stigmatizing articles increased significantly from 2011 to 2020. There is a statistical difference in the proportion of stigmatizing codes between articles featuring SMI and CMD (χ² = 44.56, p < .001) and different sources of information (χ² = 78.49, p < .001). And the statistical difference remained over the decade.

Conclusion:

The results of the research indicate that the media may have alleviated the problem of stigma. But the subtle stigmatization still exists, which needs joint efforts of the government and media.

Keywords

Policy development media portrayal China Daily stigma

Introduction

Mental illness is a global issue. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 showed that more than 13.04% of the world’s population has been affected by mental disorders at some point in their life (Vos et al., 2020). Up to 970 million people suffer from different mental disorders, including depression, bipolar disorder, schizophrenia, and dementia worldwide. Although mental disorders are highly prevalent in the world, people with mental disorders are confronted with unignorable challenges. They generally anticipated or experienced more difficulties in finding jobs, receiving education, sustaining intimate relationships and facing worse medical conditions (Momen et al., 2020; Rössler, 2016; Thornicroft et al., 2009). Stigma is a big challenge for people living with mental disorders. Stigma refers to the disparaging and insulting label of particular groups of people (DeFleur & Goffman, 1964). People with mental illness are excluded, feared, and avoided in all aspects of life, including the work environment, job hunting, and public service (Corrigan & Penn, 1999; Corring, 2002; Link, 1987). They are rejected from getting employed, earning satisfactory income and accessing medical services (de Vries et al., 2018; Gamm et al., 2010; Link & Cullen, 1990). Worse still, the fear of stigma could cause many patients with mental disorders to delay seeking help (Arboleda-Flórez, 2001).

People’s understanding of mental disorders can predict their attitudes toward people with mental disorders (Gong & Furnham, 2014; Jorm, 2000; Link, 1987). The general public often has little contact with people with mental disorders in daily life, and the media becomes the primary source of information (Clement et al., 2013; Klin & Lemish, 2008; Reavley et al., 2011). The past 30 years have seen increasingly rapid advances in the research of how media produce, shape, and reduce the stigma of mental disorders. On the one hand, the media can promote the public’s knowledge and understanding of mental disorders to reduce prejudice (Clement et al., 2013). Existing research has shown that just watching or reading positive news about schizophrenia can significantly increase knowledge acquisition and influence stigma reduction (Corrigan et al., 2013; Ritterfeld & Jin, 2006; Ross et al., 2019) .

On the other hand, negative news or reports are likely to exacerbate stigmatizing attitudes toward people with mental disorders. A study of 1,999 pieces of newspapers showed that the negative news about mental disorders in media far outweighs the positive ones due to internalized stereotypes (Wahl, 2003). Brown and Bradley (2002) found that people’s misattributions of mental disorders are related to negative depiction in the news and entertainment (Brown & Bradley, 2002). And the media are prone to aggravate people’s beliefs and thoughts on the association between mental disorders and violence, which further discourages people with mental disorders from seeking help (Arboleda-Flórez & Stuart, 2012; Asnis et al., 1997; Monahan, 1992; Parrott & Parrott, 2015). In mainland China, it is widely believed that the policy agenda determines the media agenda, and this impact may be more seen in the official media (Luo, 2013; Zhang et al., 2012). In the past 10 years, the domestic mental health service in China has experienced vigorous development, especially since the government has introduced a large number of national mental health policies. In October 2012, to protect the legitimate rights of people with mental disorders, the Chinese government first introduced the Mental Health Law (President Order No.62) and amended the bill in 2018 (Chen et al., 2012). To strengthen the prevention, diagnosis, and treatment of mental disorders, multiple Chinese government departments successively published the National Mental Health Work Plan (2015–2020), the Outline of the ‘Healthy China 2030 ’, the Guidelines on Strengthening Mental Health Services, the work rules for the management and treatment of serious mental disorders (2018 edition) and the Pilot Work Plan for the Construction of the National Social psychological Service System (Announcement, 2017; Chen et al., 2019; National Health Commission of the People’s Republic of China, 2018; Editorial Office of China Social Work, 2019; Xiong & Phillips, 2016). These policies cover all aspects of mental health-related topics, including laws and human rights, medical system improvement, personnel training and social health awareness.

While many studies focus on policies, few studies have touched on what changes the policies brought to the media. Many mental health policies have provided clear guidance and norms for media reports, to reduce the stigma of people with mental disorders. Therefore, this study aims to understand what national policies have the Chinese government issued that involve publicity and media education on mental health. What is the possible impact on media coverage? What are the possible problems in the existing media reports that can inform China’s mental health policies in the future?

This study consists of two parts, policy review and media review. The policy review focuses on mental-health policies that specify the publicity and media coverage of mental disorders. The media review’s main objective is to compare the change and relationship in the depiction of mental disorders, classifications of mental disorders, and sources of information over time between 2011 and 2020.

In this study, we delve into a major domestic state media, China Daily. China Daily is a significant and dominant media in China (Zhang & Wu, 2017). It is the leading English newspaper and one of the 18 state-owned media with 52 million daily visits. State media is particularly interested in expressing the will of the government and mobilizing citizens to take actions (Gehlbach & Sonin, 2014). As an influential media in domestic China and the world, this newspaper is published in three languages, representing the Chinese government’s voice and diplomacy. Compared with other state media, China Daily covers diverse topics and content. Thus, China Daily is a specifically suitable material for tracking the change in the Chinese media’s reporting attitudes, sensitively reflecting the dynamic relationship between policy change and media portrayal of mental disorders.

We hypothesized that (1) From 2011 to 2020, stigmatizing descriptions would decrease and anti-stigmatizing descriptions would increase; (2) There are significant differences in media portrayals that include different types of mental disorders; and (3) There are significant differences in media portrayals of different sources of information. And an exploratory analysis was conducted to explore how the depiction changes around important time points of policy publications.

Method

Policy review

The purpose of this section is to deepen our understanding of the relationship between mental health policies and media reports. A review of Chinese national plans, policies and laws on mental health from 2011 to 2020 was undertaken, mainly focused on the supervision and management of media reports.

Source of policy literature

Policy literature was collected from the Chinese State Council Policy Document Repository (www.gov.cn); pkulaw.cn (https://www.pkulaw.com/); Peking University Legal and Italian Database (http://www.lawyee.net/); iPolicy Analysis System (http://39.105.58.246/ipolicy/); CNKI database (https://zhengbao-cnki-net-443.web.bisu.edu.cn/kns55/index.aspx?dbcode=cjfz) and China Political Bulletin and Bulletin Periodical Literature Database (http://policy.drcnet.com.cn/home). All the policy literature was published between 2011 and 2020. The keywords searched in the database include ‘psychology (mentality; mind; psychic) OR mental health’. Criteria for selecting the policy literature were as follows: (1) the policies and regulations are mental health-related and (2) put forward the regulatory content of the media.

Media review

The media review used China Daily reports on mental disorders from 2011 to 2020 as a sample. The number of reports, year of reports, source of information, the depiction of people with mental disorders, and classifications of mental disorders were coded.

Source of newspaper

Research material was collected from news articles reporting mental illness-related topics between 2011 and 2020 on China Daily. All the articles were published in every study year from 2011 to 2020. One thousand and twenty search results were drawn from Factiva (https://www.dowjones.com/professional/factiva/), the database of over 30,000 global newspapers, using Boolean operators on newspaper themes: ‘mental illness’ OR ‘mental health’ and limiting the Date: 01/01/2011–31/12/2020, Source: China Daily and language: English. We used the database filter to delete duplicates.

Exclusion and inclusion criteria

In this study, all the articles received a two-step review to determine their eligibility for content analysis. The two-step review refers to (1) title review: their titles include ‘mental illness’, ‘mental disorder’, or any specific mental illness (e.g. ‘depression’, ‘schizophrenia’), or (2) full-text review: the content of the newspaper articles targeted or was highly related to mental health. Articles were excluded if the context is unrelated to mental health (e.g. Former intern gets a job after rejection over HIV test result) or if the diagnostic terms were used non-clinically (e.g. Relevant policies have sparked anxiety in economic markets). After the review, a total of 572 articles were included in the following coding process (Figure 1).

Figure 1.

Selection process of articles.

Coding of elements

With the utilization of NVIVO 12, we combined mental illness depiction in pre-existing literature and open coding to determine the nodes and sub-nodes (Li et al., 2021; McGinty et al., 2016). All the articles were coded by two well-trained researchers using the same code book. Before formal coding, the two researchers coded a sample article in 2011 and compared their results to reach an agreement. A kappa agreement test was used to determine the extent of agreement, with a threshold of 0.7 (Anderson et al., 2020; Li et al., 2021). For any uncertainty or disagreement, the two researchers should discuss to reach a consensus.

The articles were coded in terms of date, depiction of mental disorders, classifications of mental disorders and source of information (details see attached codebook). The depiction of mental disorders was classified into three categories: ‘anti-stigmatizing ’, ‘stigmatizing’ and ‘mixed’. ‘Stigmatizing’ depiction includes violence/danger/harm to others, helpless victims, burden/problems to family and friends, strange behavior, negative language and in-curability of mental disorders.

‘Anti-stigmatizing’ depiction includes positive descriptions of people with mental disorders, prevalence, causes or treatment of mental disorders, knowledge on mental health, pointing out the stigma problem on mental disorders and problems of existing mental health services (and solutions). Mixed depiction refers that both anti-stigmatization and stigmatization depictions being present in the article.

Classifications of mental disorders were categorized into common mental disorder (CMD), severe mental illness (SMI) and not mentioned. According to Work Rules on Management and Treatment of Severe Mental Disorders (National Health Commission of People’s Republic of China, 2018) issued by the Chinese state council, SMI include schizophrenia, schizoaffective disorder, paranoid psychosis, bipolar (affective) disorder, mental disorders caused by epilepsy, and mental retardation with mental disorders. In addition, if a person shows symptoms of self-harm or threatens the safety of others and is diagnosed with mental disorders, the condition is assessed as severe mental illness (National Health Commission of People’s Republic of China, 2018). CMD refer to what is mentioned in DSM-5 and ICD-11 in addition to SMI (including non-specific wording such as ‘mental disorders’, ‘mental disease’, or ‘mental illness’).

Sources of information include mental health professionals (including social workers and volunteers community, and medical institutions/professionals) and non-mental health professionals (governmental agencies, private companies/individuals and People with mental disorders). The detailed codebook was established during the coding process and uploaded as a supplementary document.

Analysis of statistics

Statistical analysis was performed using NVIVO 12 and SPSS software (version 20).

The proportion and frequency of depiction of mental disorders, classifications of mental disorders and source of information were counted by year. The first hypothesis was tested by comparing the codes of the depiction of mental disorders over time. The second and third hypothesis was testified by Chi-test to determine whether significant depiction differences can be detected in different classifications of mental disorders and sources of information. The exploratory analysis was conducted using the Mantel–Haenszel method.

Result

Policy literature

The Mental Health Law enacted in 2012 stipulates that no organization or individual may discriminate against, insult or maltreat people with mental disorders, or illegally restrict their freedom (Chen et al., 2012). News reports and artistic works should not contain any content that discriminates against or humiliates people with mental disorders. The National Mental Health Work Plan (2015–2020), issued in 2015, calls for vigorous publicity and education on mental health to guide the public to correctly understand mental disorders and psychological behavior problems (Xiong & Phillips, 2016). This plan also aims to actively create a social atmosphere of understanding, acceptance and care for people with mental disorders.

In 2018, Work Rules on Management and Treatment of Severe Mental Disorders, which first specified the definition of serious mental disorders, came up with carrying out various forms of mental health campaigns on traditional media and new media (such as radio, TV, books, film and television, animation, advertisements, websites, WeChat, and Weibo) (National Health Commission of People’s Republic of China, 2018). The work rules also highlight the importance of popularizing the Mental Health Law and mental health-related policies and increasing the public understanding of mental health and mental health services.

In August 2020, the General Office of the National Health Commission drafted the special service work plan for the prevention and treatment of depression and dementia. This work plan clarified the importance of depression and dementia knowledge publicity with a variety of media forms, to raise public awareness and reduce prejudice and discrimination (National Health Commission of People’s Republic of China, 2018).

Several mental health policies specifically regulate media coverage, especially in 2012, 2015, and 2018. In the Media Review, we will pay special attention to the changes in media coverage before and after the introduction of the policy over the 10 years.

Media evidence

Table 1 shows an overview of the frequency and proportion of all the codes and sub-codes after the analysis of 572 articles. Overall, 14.2% of the articles were coded as stigmatizing, 67.8% of the articles as anti-stigmatizing and 18% of the articles as mixed. 40.4% of the stigmatizing codes depicted mental disorders as violence/danger/harm to others, followed by 29.8% of the codes depicting people with mental disorders as helpless victims, and 11.6% of the codes depicted people with mental disorders as burden/problems to their family and friends. As for the anti-stigmatizing portrayal of mental disorders, 42.5% of the codes point out the problems of existing mental health services and solutions, the other 22% focus on the prevalence, causes and treatment of mental disorders and 18.6% of the codes delivers knowledge on mental health. Turning to the source of information, the major sources are governmental agencies (22.2%), academic and research institutions (20.7%) and medical institutions and professionals (19.2%). The other three sources of information, people with mental disorders, private companies/individuals and Social workers and volunteers community, respectively account for 13.4%, 12.7%, and 11.8%. From this table, we can also see that common mental disorders (40.7%) and other types of mental disorders (45.7%) are more frequently mentioned than severe mental illnesses (13.6%).

Table 1.

Frequency and proportion of the portrayal of mental disorders, Source of information and Classification of mental disorders by year.

Year	2011		2012		2013		2014		2015		2016		2017		2018		2019		2020		Total
Total	37		46		78		63		46		57		61		52		60		72		572
	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
The portrayal of mental disorders
stigmatizing	5	13.5%	7	15.2%	11	14.1%	13	20.6%	9	19.6%	11	19.3%	6	9.8%	3	5.8%	11	18.3%	5	6.9%	81	14.2%
Violence/danger/harm to others	7	25.0%	8	28.6%	21	43.8%	7	30.4%	12	60.0%	10	52.6%	8	61.5%	4	22.2%	11	57.9%	3	33.3%	91	40.4%
Helpless victims	13	46.4%	10	35.7%	11	22.9%	8	34.8%	3	15.0%	3	15.8%	1	7.7%	7	38.9%	7	36.8%	4	44.4%	67	29.8%
Burden/problems to family and friends	3	10.7%	3	10.7%	8	16.7%	4	17.4%	2	10.0%	2	10.5%	1	7.7%	2	11.1%	0	0.0%	1	11.1%	26	11.6%
Strange behavior	3	10.7%	1	3.6%	2	4.2%	2	8.7%	0	0.0%	2	10.5%	3	23.1%	1	5.6%	0	0.0%	0	0.0%	14	6.2%
Negative language	0	0.0%	3	10.7%	1	2.1%	1	4.3%	1	5.0%	2	10.5%	0	0.0%	4	22.2%	1	5.3%	1	11.1%	14	6.2%
In-curability of mental disorders	2	7.1%	3	10.7%	5	10.4%	1	4.3%	2	10.0%	0	0.0%	0	0.0%	0	0.0%	0	0.0%	0	0.0%	13	5.8%
anti-stigmatizing	15	40.5%	29	63.0%	39	50.0%	40	63.5%	29	63.0%	41	71.9%	50	82.0%	38	73.1%	43	71.7%	64	88.9%	388	67.8%
positive description of people with mental disorders	6	11.5%	5	6.5%	10	8.7%	8	9.8%	5	8.3%	5	7.4%	6	7.2%	5	6.3%	8	10.8%	5	4.7%	63	7.9%
Prevalence, Causes and Treatment of mental disorders	17	32.7%	21	27.3%	30	26.1%	26	31.7%	19	31.7%	12	17.6%	17	20.5%	15	19.0%	8	10.8%	10	9.3%	175	22.0%
Knowledge on mental health	3	5.8%	11	14.3%	12	10.4%	15	18.3%	7	11.7%	19	27.9%	21	25.3%	22	27.8%	17	23.0%	21	19.6%	148	18.6%
Pointing out the stigma problem on mental disorders	5	9.6%	10	13.0%	17	14.8%	8	9.8%	6	10.0%	8	11.8%	4	4.8%	2	2.5%	4	5.4%	8	7.5%	72	9.0%
Problems of existing mental health services (and solutions)	21	40.4%	30	39.0%	46	40.0%	25	30.5%	23	38.3%	24	35.3%	35	42.2%	35	44.3%	37	50.0%	63	58.9%	339	42.5%
Mixed^*	17	45.9%	10	21.7%	28	35.9%	10	15.9%	8	17.4%	5	8.8%	5	8.2%	11	21.2%	6	10.0%	3	4.2%	103	18.0%
Source of information
Mental health experts	36	50.0%	36	51.4%	63	49.6%	56	60.2%	26	54.2%	43	54.4%	53	48.6%	53	55.8%	56	46.3%	80	51.6%	502	51.8%
Academic and research institutions	13	18.1%	12	17.1%	20	15.7%	17	18.3%	17	35.4%	20	25.3%	26	23.9%	23	24.2%	24	19.8%	28	18.1%	200	20.6%
Medical institutions and professionals	17	23.6%	21	30.0%	34	26.8%	24	25.8%	6	12.5%	11	13.9%	14	12.8%	16	16.8%	11	9.1%	34	21.9%	188	19.4%
social workers and volunteers community	6	8.3%	3	4.3%	9	7.1%	15	16.1%	3	6.3%	12	15.2%	13	11.9%	14	14.7%	21	17.4%	18	11.6%	114	11.8%
Non-Mental health experts	36	50.0%	34	48.6%	64	50.4%	37	39.8%	22	45.8%	36	45.6%	56	51.4%	42	44.2%	65	53.7%	75	48.4%	467	48.2%
The governmental agencies	16	22.2%	14	20.0%	28	22.0%	21	22.6%	12	25.0%	18	22.8%	23	21.1%	14	14.7%	27	22.3%	41	26.5%	214	22.1%
People with mental disorders	16	22.2%	17	24.3%	25	19.7%	14	15.1%	5	10.4%	9	11.4%	11	10.1%	11	11.6%	13	10.7%	9	5.8%	130	13.4%
Private companies/individuals	4	5.6%	3	4.3%	11	8.7%	2	2.2%	5	10.4%	9	11.4%	22	20.2%	17	17.9%	25	20.7%	25	16.1%	123	12.7%
Classification of mental disorders
Severe mental illness	14	35.9%	8	17.4%	24	30.8%	19	27.9%	24	46.2%	14	24.6%	21	33.9%	13	25.0%	13	21.7%	11	15.3%	161	27.5%
Common mental disorders	13	33.3%	20	43.5%	22	28.2%	28	41.2%	8	15.4%	16	28.1%	17	27.4%	22	42.3%	24	40.0%	35	48.6%	205	35.0%
Not mentioned	12	30.8%	18	39.1%	32	41.0%	21	30.9%	20	38.5%	27	47.4%	24	38.7%	17	32.7%	23	38.3%	26	36.1%	220	37.5%

Mixed: Both anti-stigmatization or stigmatization elements were present.

Figure 2a compares the number of articles featuring different portrayals of mental disorders by year. What stands out in the figure is that despite some fluctuations, the number of anti-stigmatizing articles increase significantly from 2011 to 2020, especially after the publication of the National Mental Health Work Plan in 2015 and the work regulations for the management and treatment of serious mental disorders in 2018. However, no significant change in the number of stigmatizing articles was found.

Figure 2.

The number of articles featuring different portrayals of mental disorders by year and Proportion by Classification of mental disorders and sources of information: (a) the number of articles featuring different portrayal of mental disorders by year, (b) proportion of articles featuring different portrayal of mental disorders by Classification of mental disorders, and (c) proportion of articles featuring different portrayals of mental disorders by source of information.

Classification of mental disorders and media portrayal

From Figure 2b, we can see the proportion of stigmatizing codes is higher in articles featuring SMI (34.6%) than those featuring CMD (4.7%). In comparison, anti-stigmatizing portrayals are more frequent in articles featuring CMD (73.8%) than those featuring SMI (41.5%). Further Chi-squared test analysis showed that there is a statistical difference (Table 2) in the proportion of stigmatizing codes between articles featuring SMI and CMD (χ² = 44.56, p < .001). As 2018 is the year an official document was issued by the Chinese government to distinguish between SMI and CMD, we wanted to know how media portrayals changed before and after the policy was introduced. From Table 3, the overall adjusted odds ratio and odds ratio before and after 2018 are statistically significant.

Table 2.

Media depictions of different types of mental disorders and sources of information.

	Number	Stigma [N (%)]	Anti-stigma [N (%)]	Difference and 95% confidence interval (%)	Chi-squared (p-value)
Classification of mental disorders
CMD	161	9 (5.6%)	152 (94.4%)	31.6 [22.29, 40.91]	44.56 (<.001)
SMI	121	45 (37.2%)	76 (62.8%)	31.6 [22.29, 40.91]	44.56 (<.001)
Source of information^a
Mental health professionals	396	14 (3.5%)	382 (96.5%)	22.58 [17.69, 27.46]	78.49 (<.001)
Non-mental health professionals	360	94 (26.1%)	266 (73.9%)	22.58 [17.69, 27.46]	78.49 (<.001)

Note. CMD = common mental disorders; SMI = severe mental illness.

Mental health professionals (including Academic and research institutions; Medical institutions and professionals; social workers and volunteers community); non-mental health professionals (including governmental agencies; People with mental disorders and Private companies/individuals).

Table 3.

Differences in stigmatizing article numbers from non-mental health professionals versus mental health professionals, or featuring Common Mental Disorder versus Severe Mental Illness in the China Daily from 2010 to 2020.

Year	Chi-square Tests		Odds ratio	[95% confidence interval]
	Chi-squared	p Value		[Upper limit, lower limit]
			Odds ratio^a
2011–2012	7.40	.007	8.70	[1.18, 64.08]
2012–2015	29.79	<.001	7.62	[3.08, 18.83]
2015–2018	22.64	<.001	9.41	[2.91, 30.39]
2018–2020	20.74	<.001	6.00	[2.41, 14.97]
Overall OR Adjusted for year			7.39	[4.29, 12.71]
			Odds ratio^b
2011–2018	28.75	<.001	6.30	[2.77, 14.30]
2018–2020	17.07	<.001	8.25	[2.48, 27.45]
Overall OR Adjusted for year			6.65	[3.39, 13.08]

Odds ratio that a stigmatizing article from non-mental health professionals versus mental health professionals, by year published. Mental health professionals were taken as the reference group.

Odds ratio that a stigmatizing article featuring Common Mental Disorder versus Common Mental Disorder, by year published. Common Mental Disorders were taken as the reference group.

Source of information and media portrayal

Figure 2c shows the proportion of articles featuring different portrayals of mental disorders by the source of information and classification of mental disorders. For different source of information, the proportion of stigmatizing codes are high from the source of private companies/individuals (19.5%), governmental agencies (17.8%) and people with mental disorders (14.6%), while the proportion of stigmatizing articles from academic institutions, medical professionals and volunteers communities are less than 4%. And the proportion difference between different media depictions of the two mental health professionals and non-mental health professionals is significant (χ² = 78.49, p < .001), as shown in Table 2.

Since we wanted to explore changes in media portrayals before and after the release of policies, we segmented the data according to the time point of the policy release, which is 2012, 2015, and 2018. Although OR values were significant at every time period and overall, stigmatizing codes from non-mental health professionals are more frequently seen than mental health professionals (in Table 3).

Discussion

To our knowledge, this study is the first to explore the relationship between media portrayals, source of information and classification of mental disorders from a policy perspective in China.

The first hypothesis is partly supported. Although only 14.2% of the 572 articles were stigmatizing, stigmatizing descriptions remained the same level over the 10-year period. Over time, especially after the publication of the National Mental Health Work Plan in 2015 and the work rules for the management and treatment of serious mental disorders in 2018, articles featuring anti-stigmatizing portrayals rose significantly. The second and third hypotheses are strongly supported. Media reports citing non-mental health professionals (including governmental agencies and private companies/individuals and people with mental disorders) contain more stigmatizing content than mental health professionals, including academic organizations, social workers and medical institutions. As for different types of mental disorders, a higher proportion of stigmatizing articles in articles featuring SMI than CMD. However, the relationship between media portrayal, sources of information and classification of mental disorders was not improved after policy promulgation.

Although we could not directly connect the change in media with government policies, the first study finding and policy review indicate that the government’s policies play a positive role in increasing anti-stigmatizing content. As mentioned in the literature review, strong political power greatly drives the way the media report news (McCombs & Guo, 2014; Mrogers & Wdearing, 1988; G. Zhang et al., 2012). The effect of such publicity is very significant. In the past decade, people’s mental health awareness has improved. In 2020, 94.0% of the respondents believe that mental health is important, increasing by 6.1% from 2008 (Fu et al., 2021). Mental health knowledge in self-regulation and interpersonal communication is in high demand.

However, the stigmatizing content was not well controlled. It is true that stigmatizing content remained a low proportion over the 10-year period. A potential explanation might be the target readers of China Daily are highly educated Chinese and expats. Thus, this newspaper, as the public diplomacy of Chinese government, tends to report less stigmatizing content. However, more implicit stigmatization still exists. The stigmatizing content depicts people with mental disorders as dangerous, helpless and incurable and the situation has not been promoted over the 10-year period. The national mental health report shows less than half of respondents say they need knowledge about mental illness (Fu et al., 2021). And past research confirms that the subtle and inaccurate stigmatizing depictions in media, emphasizing the danger, vulnerability and incurability of people with mental disorders could predict negative public attitudes and awareness (Knifton & Quinn, 2008; Stuart, 2006). Subtle forms of stigmatization still remain. The second finding indicates that information from non-mental health professionals is more stigmatized than mental health professionals. Consistent with previous research, mental health professionals, including social workers, researchers and psychiatrists, are less likely to show stigma toward their clients (Ahmedani, 2011). To maintain story balance and objectivity, however, journalists in most cases choose to directly cite multiple sources of information (Hopmann et al., 2012). Some information may be originally stigmatized and distorted. The media industry’s coverage of mental disorders needs to pay more attention to false information and stigmatized content from unprofessional sources of information in the future. The third study finding is consistent with past research conducted in many other countries, that SMI is more likely associated with negative stereotypes than CMD (Hasan & Musleh, 2018; Li et al., 2021; Wood et al., 2014). Compared with CMD, the general public tends to show fear instead of neglect or anger, impeding people with SMI from being accepted by society (Penn & Martin, 1998). The more negative portrayal of SMI may exacerbate the existing public stigma.

In addition, the exploratory analysis extends past research to the relationship between policies and media portrayal. Stigma from non-mental health professionals and against SMI was not significantly improved during the decade. The lack of increase in non-stigmatizing articles written by non-professionals can be considered as the less impact of policy change on non-professionals. Despite the policy change, non-professionals might be less motivated to know relevant knowledge and policy content. The lack of increase in non-stigmatizing articles featuring SMI may indicate that stigma against SMI is hard to change. In addition, the Chinese government requires medical institutions to record and report people with SMI to national information system for management and treatment. Although this system can guarantee the long-term life quality of people with SMI, the impact of this measure on the stigmatization of SMI is still unknown.

Limitations

Unfortunately, our understanding may not be exhaustive only with China Daily. The study is limited by the lack of both new media and unofficial media. Television, magazines and the internet are all primary information sources of mental health knowledge (Reavley et al., 2011). More research is needed to cover more types, regions and forms of media to develop a more comprehensive overview of the media’s role in the publicity of mental disorders in China and promote future anti-stigma work. Second, another limitation of this study is that it only considers political factors and ignores the influence of other factors on the media. The business and economic boom in the mental health industry in China may attract more media attention. Merely from March to April 2020, the national consumption of mental health Apps surges by more than 60% (Shang et al., 2019). Urbanization over the past decade is also a possible explanation for the change in media. The mental condition and health services of the urban population are significantly better than that of the rural population (Fu et al., 2021). And experiences of discrimination and perceived social inequalities in rural-urban migration are strongly linked to mental health problems (Lin et al., 2011). Along with the rural-urban migration, the media may notice increasing mental health problems. Developments in technology, such as the use of social media, have also encouraged the wider dissemination of specific mental health issues (Sumner et al., 2020). A further retrospective study could explore how other factors influence media coverage in the future.

An additional limitation is the stigma in our study, as assessed by researchers, is inherently subjective. Stigma is a profound concept, including public stigma, self-stigma, structural stigma and other subtypes of stigma (Sheehan et al., 2017). To gain a comprehensive understanding, future research could invite different groups to read and give their definitions of stigma in the media reports.

Implication

Reducing the stigma of mental disorders in media coverage requires a concerted effort by both government departments and media agencies. For the government, promulgating relevant management measures may not be enough. Training for reducing stigmatizing media reporting is still a must. Other countries also have similar training in the form of scholarships or short-term programs. For example, Rosalynn Carter Fellowships for Mental Health Journalism supports journalists around the globe to report mental disorders accurately by providing funding, training sources and media platforms. As such, the Chinese government can also hold similar events. The government can also further standardize the key media platforms’ reporting content and language about mental disorders. The media should reduce the use of negative language about mental disorders, suggestive labeling and the unreasonable association between violence, vulnerability and people with mental disorders. Journalists need to be more aware of their responsibilities to people with mental disorders. They should be more cautious about reporting severe mental disorders such as schizophrenia. More scrutiny is necessary for information from different sources, especially non-mental health experts. A further study could assess the journalists’ mental health knowledge and internalized perception of mental disorders.

Conclusions

This is the first study to explore the relationship between media portrayals, source of information and classification of mental disorders from a policy perspective in China. The results show that the number of anti-stigmatizing articles increased significantly.

However, the number of stigmatizing articles remained unchanged. Stigmatizing depictions were significantly more seen in media reports featuring severe mental illness and non-mental health professionals, which was not improved by the introduction of government policies. In general, it seems that the subtle stigma of mental disorders remains in the media. Greater efforts of the government and media are needed.

First, the limitation of this study includes paucity of multiple media. Second, this study lacks consideration of other influencing factors, including the prosperity of mental health industry, urbanization and the use of social media. Third, our understanding of stigma is limited and in this study. The study should be repeated covering more types, regions and forms of media. The understanding of stigma can be extended by involving more groups of people in the research. A further study could explore how other factors influence media coverage.

Supplemental Material

sj-docx-1-isp-10.1177_00207640231162815 – Supplemental material for An exploratory study on the 10-year dynamic changes of mental health policy development and media stigma reporting in China (2011–2020)

Supplemental material, sj-docx-1-isp-10.1177_00207640231162815 for An exploratory study on the 10-year dynamic changes of mental health policy development and media stigma reporting in China (2011–2020) by Shuo Li, Yawen Shi, Tianzhen Chen and Min Zhao in International Journal of Social Psychiatry

Footnotes

Author contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Shuo Li and Yawen Shi. The first draft of the manuscript was written by Shuo Li and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Natural Science Foundation of China (81771436, 82130041, 82201650), Shanghai Shenkang Hospital Development Center (SHDC2020CR3045B), Shanghai Key Laboratory of Psychotic Disorders (13DZ2260500), Shanghai Rising-star Cultivation Program (22YF1439200), Capability Promotion Project for Research-oriented Doctor at SMHC (2021-YJXYS-01), Shanghai Municipal Science and Technology Major Project (2018SHZDZX05), Shanghai Engineering Research Center of Intelligent Addiction Treatment and Rehabilitation (19DZ2255200), Shanghai Clinical Research Center for Mental Health Q6 (19MC1911100), Shanghai Science and Technology Program (21DZ2201000), and Lingang Lab (Grant LG202106-03-01).

Ethical approval

Ethics committee approval was not required for this study.

ORCID iDs

Shuo Li

Tianzhen Chen

Data availability

All data will be shared on request.

Supplemental material

Supplemental material for this article is available online.

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