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INTRODUCTION
Posttraumatic Stress disorder (PTSD) is a common anxiety disorder that develops after a person is exposed to a life threatening traumatic event (1). In Korea, the illness affects about 1.2%-1.6% of individuals in their lifetime (2, 3); however, the prevalence reaches 8% of the general population in the US (4). The rate of PTSD in women is two times higher than men in both countries (2-4). The symptoms of PTSD include re-experience of trauma through flashbacks or nightmares; avoidance of stimuli associated with the original event; and increased arousal such as insomnia, hypervigilance, and anger. Most often, these symptoms develop shortly after the traumatic event; however, in some instances they can emerge as late as many years after the incident (1).
The course of illness is typically chronic although many patients eventually achieve symptomatic remission (4, 5). A recent long-term general population study revealed that 92% of individuals with PTSD remitted but their median time to reach such remission was 14 yr (5). Another epidemiological study found that one third of cases persisted for more than five years (6). This study also showed that the chance of remission goes down if PTSD persists for a year thus emphasizing early detection and intensive treatment of PTSD within the early course of illness. Additionally, the National Comorbidity Study (NCS) estimated that those who receive treatment remit roughly two times faster than those who are not treated (4).
Despite the need for proper treatment, many patients with PTSD unfortunately do not access treatment facilities. Research shows that only 15%-30% of veterans with trauma-related mental disorders receive any mental health treatment (7, 8). Similar rates of mental health visit were found among those with civilian PTSD. For example, in persons with possible PTSD from community violence, one study found that only 20% sought mental health help within the year after assessment (9). An epidemiological study also noted that only 20% of civilians with PTSD symptoms visited mental health professionals in the past six months (10). Thus, a tremendous demand exists to assist and inform those with PTSD to seek appropriate professional treatment.
The first step in seeking help is to recognize the problem; the NCS reported that more than half of those with untreated mental illness did not regard themselves as having any clinical condition requiring treatment (11). Additionally, a population based study revealed that better knowledge of mental illness predicts help-seeking (12). Therefore, providing good information or education for those with PTSD is crucial for promoting help-seeking and at the same time effective as well (13, 14).
Although the Internet has increasingly become an important source, the public has been accessing the print media, magazines or newspapers, for health information (15-17). A survey of individuals with PTSD who had called the Anxiety Disorder Association of America for further information revealed that newspapers and magazines were the most frequently used source for referral, followed by books and television/radio (18). Moreover, the newspaper companies provide the news articles through their websites blurring boundary between Internet and print media. In Korea, major newspaper homepages have more than 10 million visits a month (19).
Previous research has indicated that concern exists for inaccurate information and portrayal of negative image of mental illness in the media (20-23). A Canadian study investigated information provided by web sites on treatment of schizophrenia and attention deficit hyperactivity disorder and found that the quality was generally poor and misleading (24). News media often portrays negative views of mental illness and to make matters worse, this stance remains unchanged over the time (25). With regard to PTSD, the media may become a source triggering PTSD symptoms through indirect exposure (26). And most patients with PTSD respond with negative emotions such as sadness and fear to media reports of their traumatic events (27).
Despite these negative aspects, it has been shown that the media can assert a positive effect on the public, for example, after the outbreak of a disaster. It can provide information on emotional reactions, coping strategies, risk factors and resource for support and professional help (28, 29).
It is commonly believed that since the 9/11 terrorist attack, PTSD has become one of the more commonly covered mental health problems in the media. However, the content of articles dealing with this illness has not been a subject of scientific investigation. Most studies involved mental disorder in general, violence by the individuals with the serious mental illness, or schizophrenia (20, 21, 25).We were interested to find out whether the number of articles describing PTSD in the Korean print media continues to grow and how accurately and appropriately the newspapers report the cause, the symptoms and treatment of PTSD. Thus, articles from three nationally representative daily newspapers were investigated.
MATERIALS AND METHODS
Sampling
By circulation, the three major daily newspapers in Korea were chosen: The Chosun Ilbo, Jungang Ilbo, and Dong-A Ilbo (30). These three newspapers account for about half of total circulation among national daily papers of Korea. Articles including features and news articles in each newspaper's online database were searched from the very first article available on the system (before 1965 at the latest) to December 31, 2010.
We selected articles containing the Korean terms corresponding to "post-traumatic stress disorder," "post-traumatic stress," "psychological trauma" and "traumatic stress" in the headings and contents of the articles. To prevent missing possible related articles, we also examined articles containing the words, "trauma" and "stress."
Procedures
The first author carefully examined all the articles and excluded the irrelevant ones. The articles were then coded for the year of publication, nature and category of traumatic events, and target survivors. When the survivors' stories were given, the author classified the described symptoms as Criterion A (traumatic event), B (re-experience), C (avoidance/numbing), and D (hyperarousal) if any. Other symptoms such as dissociation, depression, guilt, suicidal thoughts, and psychotic symptoms were also coded. If any treatments were mentioned, they were also coded according to the type of therapy.
Causes scale and Treatments scale
The Causes scale and Treatments scale were developed by Mansell and Read (31) for a study of website information on PTSD. These Likert-type scales address the viewpoint and orientation of the pertinent web site on the etiology and treatment of PTSD. The Causes scale investigates the theoretical orientation on the cause of PTSD: 1 = event only; 2 = event/biological or event/genetic-constitutional; and 3 = event, genetic-constitutional, and biological. The Treatments scale measures the emphasis of either psychological treatments or medication for treating PTSD: 1 = only psychological treatments were mentioned; 2 = greater emphasis was given to psychological treatments but medications were mentioned; 3 = equal emphasis on medication and psychotherapy; 4 = greater emphasis on medication, but psychological treatments were mentioned; 5 = only medication was stated. Inter-rater reliability of kappa 0.87 was reported only for Treatments scale by the authors (31).
RESULTS
Characteristics of articles
We initially located 141 articles and 18 were excluded as they were not pertinent to PTSD. Thus, a total of 123 articles featuring PTSD from three major newspapers from 1984 to 2010 were included. While only one article was published in 1984 and 1987, the number increased steadily then after and robustly after the mid 2000s (Fig. 1): more than half of the articles (n = 75) appeared during the last five years and 34 (28%) were found in 2010 (Table 1). Besides the trend for the gradual increase in the number of articles, certain years which had well-known catastrophes had more articles; e.g., Sampoong Department Store Collapse in 1995, Wonmook Elementary Accident in 2007, and the sinking of the Cheonan Warship in 2010.
Among the types of traumatic events, war or combat was most common (21%), followed by accidents (18%), sexual assaults (7%), and natural disasters (6%). Most survivors mentioned in the reports were adults (67%). Eighty six (70%) articles mentioned either international (n = 25) or national events (n = 62) related to PTSD, of these internationally Iraq-Afghanistan wars and domestically the Cheonan warship attack were most common.
Symptoms and treatments
Of the 123 articles, 55 (45%) described at least one PTSD symptom, i.e., intrusion (B), avoidance/numbing (C), and hyperarousal (D): B symptom (39%), C (28%), and D (22%). Other symptoms included dissociation (11%), depression (9%), guilt (7%), suicidal thoughts (7%), and psychotic symptoms (4%).
Only a small portion of the articles (n = 27, 22%) mentioned specific treatments for PTSD (Table 2). Pharmacotherapy (11%) and psychotherapy (13%) were addressed at similar rates. However, most psychotherapies mentioned were other non-specific therapies such as counseling and supportive psychotherapies; only five articles addressed cognitive behavior therapy (CBT), exposure therapy or eye movement desensitization and reprocessing (EMDR).
Causes and Treatments
Fifty two articles were relevant for the Causes scale and 46 articles (88%) described only events, while only six (12%) included both events and biological causes. Among twenty-nine relevant articles for the Treatments scale, psychotherapy only was most common treatment (n = 13, 45%) followed by psychotherapy + medication (n = 11, 38%), and medication only (n = 4, 14%).
DISCUSSION
To our very knowledge, this study is the first to investigate articles featuring PTSD in the print media. Our findings indicate that Korean newspapers provide general information not diverging from current understanding of PTSD and its treatment. However, if we look at more closely, the contents and the quality of information was poor. While about a half of articles (45%) mentioned PTSD symptoms, relatively small portion of articles (22%) mentioned treatment. More importantly, of 16 articles mentioning psychotherapies as a treatment for PTSD, only five articles addressed the empirically supported therapies such as CBT, exposure or EMDR (32). This is a substantial problem when the media is considered to be a source for health information and education for the public (29). The news media influences the health behaviors of the public by giving information that can change understanding, attitude, or help seeking intentions (33).
Secondly, we have shown the tendency of the newspapers to gradually report more articles on PTSD after the first article in 1984. Especially, more than half of the articles appeared in the late 2000s. This is by and large in line with increased public interests in health related issues in the media (34). However, given the tremendous increase in psychiatric morbidity and suicide rates in Korea (35), it may reflect the society's concern and interest in mental health. To shed some light on whether increased PTSD articles are generally in line with other mental health issues or exclusively confined to this illness, further studies are needed to compare with other mental health morbidities (25).
In addition to this general explanation, when confined to PTSD, increased articles may be a reaction to large scale traumatic events (mass disasters or wars) or events of interpersonal violence (child abuse or sexual assaults among teenagers) which have seized public attention in the last decade. In support of this view, we were able to see that most articles appeared shortly after large scale national traumatic events. For example, the surge of articles in 1995 represents the Sampoong Department Store collapse and in 2010 the Cheonan warship attack. This pattern was not observed for international events such as the 9/11 terrorist attack and the Iraq/Afghanistan war. For local journalists, these international events are not as eye catching as more proximate and pertinent domestic incidents. It has been suggested that media tend to cover mental health issues in a "reactive" manner, in which the topics are addressed by the political agenda of the time such as the events of the 9/11 terrorists' attack (36).
A second finding to note is that among the symptoms of PTSD, B symptoms were the most commonly described, followed by C and D. Intrusion or re-experience symptoms are the most distinctive feature of PTSD, while avoidance and hyperarousal overlaps with depression and other anxiety disorders (37). Furthermore, the symptoms in Criterion B are more overt and apparent to the person including nightmares, flashbacks, and intrusive trauma-related materials, that can be easily described by survivors and then detected by journalists. Although lower incidence, other symptoms, such as depression, dissociation, guilt, and suicidal thoughts appeared. These symptoms do not have diagnostic value but often associate with PTSD.
As explanations for the cause of PTSD, most articles (88%) addressed only events. This is comparable to findings of PTSD websites showing that one-third of homepages indicated the genetic-constitutional and a half of them mentioned biological dysregulation along with events (31). It is likely due to more professional nature of these websites and larger amount of information they can display. As only several articles considered other vulnerabilities or biological aspects. This view may not be of scientific and professionally informative value but may serve to lessen the stigma of the affected and to create a positive atmosphere so as not to blame the survivors. On the other hand, the newspapers need to provide more diverse and scientific aspects regarding etiology of PTSD.
Only psychotherapy or equal status between psychotherapy and medication were the most common descriptions for treatment of PTSD. Our finding is more psychotherapy oriented than a study on Internet websites on PTSD (31). This is likely due to half of their studied websites being drug-company funded, and thus more emphasis was given to medication in the treatment of PTSD. Our result is also in accord overall with recent clinical guidelines recommending psychotherapy as the first line of treatment or concurrently with medication (32).
From the results of this study, we believe that trauma professionals need to be more actively involved with the media and to try to improve the quality of information the public may follow for proper help seeking. In one study, compared to lay sources, psychiatrists' involvements fostered a positive depiction of mental illnesses in the print media (38). It was thus recommended for mental health professionals including psychiatrists to develop better terms with journalists as this may positively affect how the media portraits mental illnesses including PTSD.
This study is subject to some limitations. First, this study did not investigate who were the sources of information. A study observed that opinions of nonmedical experts were lacking in the newspaper articles about mental illnesses, and therefore medication and hospitalization were more emphasized by medical professionals (39). However, our study indicates that Korean print media delivers a relatively balanced view on treatment of PTSD. It would be interesting to note any differences in proposed treatments and views on causation of PTSD according to profession e.g. medical vs non-medical. Second, only three national newspapers were chosen and other media such as Internet and television sources were not included. More and more people are relying on the Internet as their source of health information and medical decision (40). Third, we did not include the tone of the media, which may have more impact on the public and policymakers. Further studies may investigate the positive or negative stance of the media on the survivors and PTSD itself. As shown in studies of other mental illnesses, negative views and pessimism may have the potential to influence public attitudes and policy (23).
In conclusion, our study found that newspaper articles on PTSD have increased during the last three decades and descriptions of symptoms and causes of the illness are relatively accurate and relevant; however, the quality of information on treatment is generally substandard.
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