Instead of describing depressive illnesses in terms of specific symptoms and medical terms, as they did when the era of Prozac began in the late 1980s, the printed news media are now far more likely to depict women's mental issues in relation to gender-stereotyped roles, such as marriage, motherhood, and menopause. But during the same time, descriptions of depression in men have not shifted in the same way.
The new findings, made by researchers at the University of Michigan Depression Center and just published online by the journal Social Science & Medicine, show that gender stereotypes increasingly pervade popular media discussions of mental illness.
From women's magazines to the health section of the daily paper, the study shows a shift toward the "medicalization" of deviation from women's traditional roles, and the increasing description of mental illness in emotional, not medical, terms. Meanwhile, men's depressive illness was increasingly described in terms connoting work, aggression or athletics.
These findings surprised the study's lead author, Jonathan Metzl, M.D., Ph.D. Even though the 1980s and 1990s were a time when women's roles in society were firmly rooted in both the workplace and the home, the media's coverage of women's mental health focused increasingly on the latter.
"We thought for sure that we'd find lots of articles about how these drugs helped women balance home and family, and describing them rushing off to high-paying job," says Metzl, a psychiatrist. "But that depiction was not anywhere near as common or as powerful as the stereotype of the woman as the mother and wife. Meanwhile, at a time when men were reportedly getting in touch with their feelings, men's roles as fathers or husbands -- or even men's emotions -- received nowhere near as much coverage as did the 'depression' of not performing on the job or the playing field."
Metzl notes that this trend is important for patients and their doctors, because it may influence the way they communicate with each other about mental health concerns.
"It's not that the media are doing a bad job covering these issues, but rather that gender stereotypes are pervading the way we talk about mental illness – for better or for worse," says Metzl, an assistant professor of psychiatry and director of the Program in Culture, Health and Medicine at the U-M Medical School and a member of the Women's Studies Program.
"Stereotypes are, of course, often based in lived experience," he continues. "But at the same time, many articles implied that people who don't adhere to these stereotypes need to be medicated."
The phenomenon echoes observations made in Metzl's recently released book, "Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs", which takes a historical look at advertisements for psychiatric medications in the mass media and medical journals, from tranquillizers such as Miltown in the 1950s through Valium in the 1970s and Prozac, Paxil and Serafem today.
In the book, and in an upcoming article in Ms. magazine, Metzl explores how drug ads from the 1950s to today have shown women and men with mental health concerns in light of the gender norms of the time. "When new drugs come out, they shift our categories of normal versus treatable," he explains. "And that happens in the context of preconceived cultural notions and expectations."
In the new study in Social Science and Medicine, Metzl and his colleague Joni Angel took this analysis a step further by examining hundreds of articles in newspapers and magazines from 1985 to 2000 – the time when Prozac and other antidepressants known as SSRIs came to the market and were prescribed to increasing numbers of Americans for everything from depression and anxiety to premenstrual dysphoric disorder.
They searched two media databases for all articles mentioning the terms "SSRI," "antidepressant" or "Prozac" in the years 1985, 1990, 1995 and 2000. Because the search turned up so many articles, they thoroughly examined a representative sample of 261 non-business articles in U.S. magazines and papers.
The researchers logged how many standard depression symptoms were mentioned in each article, in language consistent with the gender-neutral and well-tested terminology of the Diagnostic and Statistical Manual of mental illnesses. They also coded articles for how often the media included cultural criteria not in the DSM, such as terms related to marriage, friendship, aggression, sex, body image, work, age, athletic performance and menstruation or PMS.
The study shows that in 1985, before Prozac or other SSRIs were available, few newspaper and magazine articles used non-DSM terms in describing the effects of depression or SSRIs. In 1990, half the articles used DSM terms. But by 2000, when SSRIs were in widespread use, only 32 percent of articles included DSM terms -- and more than 90 percent of articles aimed at women included non-DSM terms related to marriage, motherhood, menstruation or menopause.
"What we saw was that the use of DSM terms went down over time, but that the non-DSM terms really shot up, and did so in gender-specific ways," says Metzl.
The only non-DSM criteria that went up in men were related to work and aggression/sports -- mostly in relation to high-profile acts of violence committed by men who were using SSRIs, or acts of aggression by high-profile athletes such as Mike Tyson. Very few articles addressed how depression and antidepressants might affect a man's marriage, fatherhood duties, or other relationships.
The result is a popular culture environment in which both patients and doctors should be aware that they may perceive depression and mental health in light of gender norms, Metzl says.
For example, a woman with undiagnosed depression may recognize some of her own symptoms in a magazine article about another woman whose depression interfered with her marriage, and who got help from medication. But a woman whose marriage is on the rocks for reasons other than depression may read the same article and perceive that the medication could help her, when in fact it probably won't.
"On the one hand, depression is under-diagnosed and under-treated, and the media can help people recognize depression in themselves or their loved ones," says Metzl. "But on the other hand, there are many other things that could be at work and not merit an SSRI prescription."
He concludes, "In an age of massive media coverage and ads, doctors and patients need to be aware of the cultural context of depression, as well as its biological basis, so they can have a more knowledgeable discussion about information contained in ads and news articles -- whether or not their visit ends in a prescription."
Now, Metzl is continuing this line of study in a way that may reveal whether doctors' own notes on patients with depressive illnesses are also increasingly including non-medical terms and descriptions. He is currently concluding an effort to code the notes in medical charts according to DSM and non-DSM terminology, to see if the cultural trends seen in advertisements and the media have reached the clinic.
"Assessing the impact of SSRI antidepressants on popular notions of women's depressive illness" Social Science & Medicine, available online while in press at www.sciencedirect.com/science/journal/02779536.
"Selling Sanity Through Gender" (tentative title), Ms. magazine, Fall, 2003
Social Science & Medicine