To the Editor: Several studies have identified low levels of mental health literacy in the general population. People often lack knowledge of psychiatric concepts or may have their own explanations of mental illness (1). Media both influence and reflect popular culture, and therefore, media analysis can be a useful tool to help us understand public perceptions. Previous studies have reported high rates of inaccurate and negative portrayals of schizophrenia in health news. Moreover, articles about non-health-related issues use the terms “schizophrenia” and “schizophrenic” metaphorically or in slang expressions.

To investigate these issues, we performed a content analysis (2) of articles published in 2007 and 2008 by the largest Brazilian national newspaper Folha de São Paulo. An electronic search included the terms “schizophrenia,” “schizophrenic,” “psychotic episode,” “psychosis,” and “psychotic.” Metaphorical usage was analyzed by a method adapted from a previous study (3).

Of 687 identified articles, 219 fulfilled the inclusion and exclusion criteria. Seventy-five (34%) addressed health issues and stories involving affected individuals, and 144 (66%) used the terms out of the medical context. Health news presented relevant information on genetic factors, the risk of drug-induced psychosis, and the benefits of psychotropic medications. However, another nine articles disseminated inaccurate information—for example, schizophrenia was associated with multiple personality—and the complexity of the disorder was not discussed. Three articles about individuals' stories described community integration. Seventeen focused on crimes allegedly committed by people with schizophrenia, and only one of these articles put the risk of violence into perspective.

The 144 articles that used the terms out of the medical context were more stigmatizing. Sixty-nine (48%) used the terms literally, and 75 (52%) used them metaphorically. Literal uses were noted in 37 fiction reviews, 14 common and inaccurate descriptions of schizophrenia, seven pejorative labels, and four comic expressions. Metaphorical meanings of these terms referred to contradiction, incoherence, splitting or multiplicity, oscillation, lack of reality, obsession, withdrawal, indecision, aggression, authoritarianism, peculiarity, intermediate state, creativity, transformation, and boldness. Approximately 80% of the metaphors (60 of 75) had a negative connotation.

One difference between our analysis and previous studies is that we identified metaphors with positive connotations (14 of 75, 19%), which associated schizophrenia terms with creativity, multiplicity, aggressiveness, and uniqueness of art. The metaphorical references to multiplicity and aggression had both negative and positive connotations. Although the analogy between schizophrenia and artistic creativity was presented in the newspaper articles as an attractive idea, this association may suggest that only people with schizophrenia who have extraordinary talents will be accepted by society (4) or that medical treatment is unnecessary. (One metaphor [1%] had a neutral connotation.)

Folha de São Paulo disseminated information that may promote mental health literacy; however, the stigmatizing messages may have overshadowed the positive ones. The analyses identified misconceptions and concerns that should be elucidated; for example, some news reports of criminal activities demanded that psychiatrists predict and prevent violent behavior.

Metaphorical usage can be distressing for affected individuals and families (1). Furthermore, use of terms pejoratively or to comic effect can be interpreted as disrespectful. It is not possible to control the use of medical language, and press censorship is unacceptable. The goal should be to change public perceptions of schizophrenia with antistigma campaigns, until the jokes and slang expressions no longer work.

This work was supported in part by a grant to Dr. Dubugras from CAPES, the Brazilian Ministry of Education. Dr. Mari is a I-A-level researcher with the National Research Council (CNPq) in Brazil.

The authors report no competing interests.