A Content Analysis of Mental Health Discourse in Popular Rap Music

Key Points

Question  Have references to mental health in popular rap songs increased from 1998 to 2018?

Findings  A content analysis of lyrics to 125 popular rap songs sampled from 1998 to 2018 revealed significant increases in the proportion of songs with references to suicidal ideation, depression, and metaphors representing a mental health condition.

Meaning  Research is needed to explore the potential positive and negative influences these increasingly prevalent mental health references in popular rap songs may have in shaping mental health discourse and behavioral intentions of US youth.

Importance  Rap artists are among the most recognizable celebrities in the US, serving as role models to an increasingly diverse audience of listeners. Through their lyrics, these artists have the potential to shape mental health discourse and reduce stigma.

Objective  To investigate the prevalence and nature of mental health themes in popular rap music amid a period of documented increases in mental health distress and suicide risk among young people in the US and young Black/African American male individuals in particular.

Design and Setting  Lyric sheets from the 25 most popular rap songs in the US in 1998, 2003, 2008, 2013, and 2018, totaling  125 songs, were analyzed by 2 trained coders from March 1 to April 15, 2019, for references to anxiety, depression, suicide, metaphors suggesting mental health struggles, and stressors associated with mental health risk.

Main Outcomes and Measures  Mental health references were identified and categorized based on Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) and Mayo Clinic definitions. Stressors included issues with authorities, environmental conditions, work, and love life. Descriptive language and trend analyses were used to examine changes over time in the proportion of songs with mental health references. Stressors were analyzed for their co-occurrence with mental health references.

Results  Most of the 125 analyzed songs featured lead artists from North America (123 [98%]). Most lead artists were Black/African American male individuals (97 [78%]), and artists’ mean (SD) age was 28.2 (4.5) years. Across the sample, 35 songs (28%) referenced anxiety; 28 (22%) referenced depression; 8 (6%) referenced suicide; and 26 (21%) used a mental health metaphor. Significant increases were found from 1998 to 2018 in the proportion of songs referencing suicide (0% to 12%), depression (16% to 32%), and mental health metaphors (8% to 44%). Stressors related to environmental conditions (adjusted odds ratio, 8.1; 95% CI, 2.1-32.0) and love life (adjusted odds ratio, 4.8; 95% CI, 1.3-18.1) were most likely to co-occur with lyrics referencing mental health.

Conclusions and Relevance  References to mental health struggles have increased significantly in popular rap music from 1998 to 2018. Future research is needed to examine the potential positive and negative effects these increasingly prevalent messages may have in shaping mental health discourse and behavioral intentions for US youth.

Psychological stress and suicide risk have significantly increased from 2008 to 2017 among people in the US aged 18 to 25 years.¹ Twelve-month prevalence of major depressive episodes has significantly increased for people aged 12 to 20 years from 2005 to 2014.² Anxiety and depression remain underdiagnosed and undertreated among young people. Anxiety affects 30% of adolescents, yet 80% of those affected never seek treatment.³ Only 50% of adolescents with depression are diagnosed before reaching adulthood.^4,5 Mental health risk especially is increasing among young Black/African American male individuals (YBAAM),⁶ who are often disproportionately exposed to environmental, economic, and family stressors linked with depression and anxiety.^7-11 Young Black/African American male individuals, and US adolescents generally, are among the least likely to use mental health services.^12-15

Corresponding with the lack of mental health treatment among US youths, the suicide rate for people aged 15 to 24 years in the US in 2017 reached its highest point since 1960.¹⁶ Among people aged 10 to 24 years, suicide rates climbed 56% from 2007 to 2017.¹⁷ Suicide rates among Black/African American youths aged 13 to 19 years increased by 60% since 2001, and in 2017, medical treatment for suicide attempts was provided to 68 528 YBAAM aged 13 to 19 years.¹⁸

Young Black/African American male individuals constitute a significant portion of the audience for rap music, which has been suggested by some scholars as a promising intervention for at-risk youth.^19,20 Rap music is one of the “most significant influences on the social development” of YBAAM.^21(p27) However, by 2018, rap music had attracted the youngest US audience demographic and was considered a favorite genre among most US youths aged 16 to 24 years, crossing all socioeconomic strata and ethnicities.²² This is significant, because US youth spend almost 40 hours per week listening to music, and listening time in the US in general has risen by 36.6% from 2015 to 2017.²³ Rap artists have also been found to serve as role models for their younger audiences, influencing the development of these young people’s identities.^24,25

The aim of this study is to investigate the prevalence of mental health themes in popular rap music to test whether mental health references have increased amid a period of increasing mental health distress and suicide risk among US youths, including and extending beyond YBAAM. Prior research on US pop music has found significant increases over time in the presence of anger, disgust, fear, and sadness cues in US pop music lyrics of all genres.²⁶ We do not know the extent to which mental health has been represented in popular music or rap in particular. However, rap artists have begun disclosing mental health struggles in the press, as evidenced by the 2017 headline “JAY-Z Gives Therapy a Major Co-Sign: ‘I Grew So Much From the Experience.’”²⁷ Research shows that celebrity mental health disclosures can diminish stigma and encourage help-seeking behavior among fans,^28-30 although positive references, such as therapy benefits, might have a different effect on listeners compared with more negative references of struggle. Herein, we examine lyrics of popular rap music for any reference to anxiety, depression, suicidal ideation, and metaphors representing mental health. We also examine lyrics for co-occurring references to known mental health stressors,^31,32 given that music artists will often connect with their audiences by referencing shared experiences.³³

The University of North Carolina at Chapel Hill institutional review board follows the Common Rule definition of human subjects (HHS Regulation 45 CFR 40.102[f]). Per the University of North Carolina at Chapel Hill Human Research Protection Program Standard Operating Procedure 101, Section 3, effective September 9, 2019, this content analysis of publicly available popular music lyrics does not meet the definition of human subjects research. Therefore, this qualitative study did not qualify for institutional review board approval or informed consent.

We analyzed the lyrics of 125 popular rap songs sampled across 2 decades beginning in 1998, the year rap music first outsold the former top-selling genre in the US, country music.³⁴ The Chart & Data Development department of Billboard provided proprietary data gratis, which identified the 25 highest ranked rap songs for the years 1998, 2003, 2008, 2013, and 2018 on the Billboard hot rap songs year-end chart. High rankings reflect song popularity in the US for a given year. Popularity is estimated based on Nielsen Broadcast Data System radio airplay data from across more than 120 market areas in the US and Nielsen SoundScan sales data from across more than 90% of the US market.³⁵ The 5-year increments of available data are in line with previous analyses of popular music that documented evolving styles and tastes.³⁶

All 25 songs from each 5-year increment were analyzed, totaling 125 songs. Of the 125 songs sampled and analyzed, a total of 105 songs (84%) featured a Black/African American male artist either as the lead artist (97 [78%]) or as a guest (8 [6%]). Nearly all songs analyzed (123 [98%]) featured lead artists from North America. The mean (SD) age of the leading artist across the sample was 28.2 (4.5) years. Prominent artists captured in the sample included 50 Cent, Drake, Eminem, Kanye West, Jay-Z, and Lil’ Wayne, among others.

The following categories of mental health references were coded: anxiety and anxious thinking, depression and depressive thinking, and suicide and suicidal ideation. First, lyrics conveying negative emotional sentiment were identified based on 2019 typology by Fokkinga³⁷ describing negative emotions, including personal provocation, agitation, repulsion, threats, desires, failings, misfortune, being overwhelmed, helplessness, lack of motivation, and general uncertainty. Relevant lyrics were further analyzed for specific reference to anxiety and anxious thinking, depression and depressive thinking, and suicide and suicidal ideation based on definitions developed using the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition)³⁸ and Mayo Clinic descriptions of anxiety and depression.^39-41 The negative emotion typology by Fokkinga³⁷ also informed the identification of anxious and depressive thinking based on references to high-arousal and low-arousal negative affect, respectively.

We added a fourth category, mental health metaphor, to account for lyrics that lacked sufficient information or context to qualify as a specific reference to anxiety, depression, or suicidal ideation. Consistent with prior research of music lyrics, we documented metaphors to provide insight into the latent meaning and semiotic systems (ie, slang) used in popular music lyrics.³⁵ We also coded all songs for references to stressors known to relate to mental health risk^8-10: issues with authorities, environmental conditions, faith, family life, financial strain, love life, social ally (friend) issues, social rivals (foe or competitor), and work life. From pilot testing, societal issues were added as a coded stressor to account for references to macrolevel strain, such as the economy, war, or national events. Table 1 provides descriptions and examples of each category of mental health reference and stressor.

From March 1 to April 15, 2019, 2 trained coders (A.K. and M.K.R.C.) independently analyzed lyric sheets for the presence (coded 1) or absence (coded 0) of each mental health reference or stressor (Table 1) across each song. Using lyrics from rap songs outside the sample, coders were trained to identify phrases matching mental health category descriptions and use surrounding lyrics to determine whether the song should be coded as 1 for the presence of the respective coding category. A random 46% of the full sample (57 of 125 songs) was then coded independently by each coder to test interrater reliability in applying the coding categories.⁴² Interrater reliability was above acceptable levels for all codes, based on Gwet AC₁ coefficients computed in AgreeStat, version 2015.6.⁴³ All Gwet AC₁ scores were greater than 0.90 except for coding the presence or absence of environmental conditions, which achieved a Gwet AC₁ score of 0.76.

Analyses were conducted using SPSS, version 25.0 (IBM Corporation). Frequencies were used to describe the prevalence of codes across rap songs within each sampled year. The Cochran-Armitage test for linear trends in proportions was used to examine whether proportions of songs with mental health references in each year increment approximated a relatively linear pattern of increase across time, using year as an ordinal variable. Cross-tabulations were used to describe the co-occurrence of mental health references and stressors associated with mental health risk. Unadjusted and Firth-adjusted logistic regressions were performed to examine which stressors were most likely to co-occur with the presence of mental health references. Regressions were performed only across songs with lyrics indicating negative emotion, excluding songs that mentioned stressors (eg, family, love) without also referencing negative emotion (ie, songs celebrating love). Statistical significance was assessed at a level of 2-sided P < .05.

Most of the 125 analyzed songs featured lead artists from North America (123 [98%]). Most lead artists were Black/African American male individuals (97 [78%]); artists’ mean (SD) age was 28.2 (4.5) years. Across all sampled years, 94 of the 125 total songs (75%) referenced negative emotion, and 57 of the songs with negative emotion (61%) referenced mental health. Specifically, 35 of the total sample (28%) referenced anxiety, 28 (22%) referenced depression, 8 (6%) referenced suicide, and 26 (21%) used at least 1 mental health metaphor. As shown in Table 2, the proportion of sampled songs per year with a mental health reference increased significantly in a linear trend from 1998 to 2018 for all categories except anxiety or anxious thinking (eg, depression and depressive thinking, 4 of 25 [16%] in 1998 to 8 of 25 [32%] in 2018; P = .03). Mental health metaphors had the largest increase, from 2 of 25 (8%) in 1998 to 11 of 25 (44%) in 2018 (P < .001). Although the number of songs referencing suicide or suicidal ideation across the total sample was small (8 [6%]), the significant increase from 1998 to 2018 is also noteworthy (P = .02). No references to suicide or suicidal ideation existed in 1998 and 2003. In contrast, 6 of the 8 total songs found with this reference came from 2013 and 2018, representing 12% of the 25 songs sampled in each of those 2 years.

The Figure shows the combined percentage of songs within each year that referenced any of the coded mental health categories. In 1998, 32% of the 25 most popular songs referenced mental health, whereas 68% of the 25 most popular songs in 2018 had these references. The pattern shown was found to be a statistically significant linear trend based on the Cochran-Armitage test. However, as evident in the Figure, the consistent pattern of increase began in 2008.

Table 3 shows the co-occurrence of mental health references and coded stressors. Love life (38 co-occurrences), environmental conditions (42 co-occurrences), and social rivalry (59 co-occurrences) were the most common stressors across the sample. Financial strain was mentioned the least in songs referencing mental health (1 co-occurrence).

Regression analyses showed a significant association between the presence of any mental health reference and the presence of references to environmental conditions (adjusted odds ratio [AOR], 8.1; 95% CI, 2.1-32.0) and love life (AOR, 4.8; 95% CI, 1.3-18.1) (Table 4). Social rivalry (AOR, 0.4; 95% CI, 0.1-1.3) was not significantly associated with the presence of any mental health reference. As shown in eTable 1 in the Supplement, no single stressor was associated with the presence of anxiety or anxious thinking references. As shown in eTable 2 in the Supplement, family life (AOR, 5.6; 95% CI, 1.2-26.9), faith (AOR, 15.1; 95% CI, 1.5-150.7), and social rivals (AOR, 0.2; 95% CI, 0.1-0.7) were significantly associated with the presence of depression or depressive thinking references.

Our analysis of 125 of the most popular rap songs in the United States sampled from 1998 to 2018 revealed a statistically significant increase in the proportion of popular rap songs referencing suicide, depression, and metaphors suggesting mental health struggles. The proportion of rap songs that referenced mental health more than doubled in the 2 decades we examined. All of the references to suicide or suicidal ideation in our sample were found among the popular songs taken from 2013 and 2018.

This increase is important, given that rap artists serve as role models to their audience, which extends beyond YBAAM to include US young people across strata, constituting a large group with increased risk of mental health issues and underuse of mental health services.^13,15,18 We cannot establish how much the increase is a response by rap artists to the increased mental health struggles experienced by audiences, although the notable increases we found in 2013 and 2018 correspond with increasing rates of depression, anxiety, and suicidal ideation.^1,2 We also cannot determine with our data whether these lyrical references to mental health are due to rap artists’ desires to self-disclose or to instigate discussions about mental health. The mean age of the leading artists in the sample was 28.2 years. Because rap is an autobiographical art form, the artists and younger adults may have observed and reflected national trends of distress experienced by themselves or people close to them.

One notable event that might explain the increase we observed was the 2008 release of rap album 808s & Heartbreaks by renowned rap artist Kanye West. 808s & Heartbreaks has been credited in the press for initiating a “wave of inward-looking sensitivity” among rappers.⁴⁴ Rolling Stone magazine named the album one of the 40 most “groundbreaking albums of all time,” noting that its openly emotional nature “served as a new template” for budding rappers.⁴⁵ The songs we analyzed from 2018 with references to mental health were from artists (ie, Drake, Post Malone, and Juice Wrld) who have acknowledged 808s & Heartbreaks as being influential to their musical style.⁴⁶

The increase we found also provides insights into how mental health is framed in rap, which can inform future research on how US youth may develop their understanding of mental health risk. Our findings with respect to the mental health metaphor category are particularly informative for understanding the language used to signal mental health. We noted phrases evoking imagery of physical conflict, for example “pushed to the edge” or “fighting my demons,” that were used to suggest mental health struggles. These metaphors were found in addition to phrases such as “I’m going crazy.” The use of different types of metaphors warrants future research, as the connotations of these phrases might affect listeners differently.

The prevalence of metaphors suggests rap artists rely on this type of indirect reference to describe mental health. This reliance on metaphors might be used to discuss this difficult subject less overtly and in a way that might be viewed as more socially accepted by peers and audiences. The increased prevalence of these metaphors might also explain why references to anxiety remained consistent rather than increasing across the decades. Some metaphors suggesting high-arousal negative experiences (eg, “fighting my demons”) might have been used to suggest anxiety without explicitly noting anxiety.

Examining our findings from an ecological framework,⁴⁷ rap music can be considered an exosystem, that is, a social system in which the listener does not directly function yet is an active participant. As an exosystem, mental health risk and connections made between mental health and certain stressors within this music are likely to influence mental health discourse at all levels surrounding the listener, from the overall culture to the individual’s peer group to the individual’s own psychology.⁴⁸ These influences might include the provision of emotional language that can be used to articulate complex emotions and improve mental health discourse among peers.^49,50 Therefore, it is important to investigate the mental health discourse in these lyrics as a first step in researching how rap music might be used to improve mental health outcomes among at-risk youth.

Placed into a larger macrosystem context, the co-occurrence we noted between mental health references and environmental conditions existed in years surrounding a December 2007 economic recession that disproportionately affected Black/African American communities and those of lower socioeconomic status. Stress caused by the recession is argued to have exacerbated already elevated rates of anxiety, depression, and domestic violence⁵¹ found in the most affected communities. Mention of financial strain was not prevalent within our sample, although materialism has traditionally been recognized as a common message within popular rap music.⁵² However, references to everyday living conditions and other environmental factors were the most consistent stressors mentioned in lyrics that also referenced mental health struggles, suggesting rap artists were connecting macro-level stress with mental health risk.

The present study is limited to the top 25 songs from Billboard’s hot rap songs year-end charts from 1998, 2003, 2008, 2013, and 2018 and does not fully represent the population of rap music between 1998 and 2018. We cannot address whether mental health references have existed in less popular songs or whether mental health references only exist in the most popular songs of the past decade. We also cannot address causation or motivations for the increased presence of mental health references within the sampled songs.

Like other content analyses of popular media, we also face the challenge of interpreting artists’ intended meanings behind their lyrics.³⁵ Our conservative coding of mental health references might have resulted in an underrepresentation of the prevalence of mental health references in this music. We are also unable to ascertain how US youth interact with this music or are positively or negatively affected by its messages. We did not code for positive or negative valence of mental health references, because inferring valence from lyrics alone would not have provided coders with intentional artistic cues (ie, vocal intonation) needed to accurately interpret sentiment. Future research is therefore needed to provide a qualitative examination of the meanings and connotations of these references to better inform our understanding of how this music can improve the mental health of its listeners or how it might lead to greater risk. For example, positively framed references to mental health awareness, treatment, or support may lead to reduced stigma and increased willingness to seek treatment.⁵³ However, negatively framed references to mental health struggles might lead to negative outcomes, including copycat behavior in which listeners model harmful behavior, such as suicide attempts, if those behaviors are described in lyrics (ie, the Werther effect).⁵⁴

The findings of this qualitative study suggest that mental health discourse has been increasing during the past 2 decades within the most popular rap music in the US. This increase has occurred in the midst of a corresponding increase in national mental health risk,^1,2,16,17 especially with respect to depressive and suicidal thoughts among YBAAM and US young people more generally, who constitute a major portion of the rap music audience. Although this study is limited in its ability to examine the effect of the variety of mental health references observed, this study supports the need for research examining the effects of rap music in efforts to reduce stigma and minimize mental health risk. As noted in a popular press article highlighting the need for more mental health discourse: “Pleas from rappers young and old are louder now than ever… When rappers open up, fans listen.”⁵⁵

Accepted for Publication: June 1, 2020.

Published Online: December 7, 2020. doi:10.1001/jamapediatrics.2020.5155

Corresponding Author: Francesca R. Dillman Carpentier, PhD, Hussman School of Journalism and Media, University of North Carolina at Chapel Hill, Campus Box 3365, Chapel Hill, NC 27599 (francesca@unc.edu).

Author Contributions: Mr Kresovich and Dr Dillman Carpentier were responsible for the final manuscript. Mr Kresovich had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kresovich, Riffe, Dillman Carpentier.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Kresovich, Reffner Collins, Dillman Carpentier.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kresovich, Riffe, Dillman Carpentier.

Administrative, technical, or material support: Reffner Collins, Dillman Carpentier.

Supervision: Riffe, Dillman Carpentier.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the Billboard Charts & Data Development department for providing access to music data, Travis ‘Yoh’ Phillips (unaffiliated), Janice Kilburn, PhD (unaffiliated), and Stephanie Willen Brown, MA (University of North Carolina at Chapel Hill) for contributing to the conceptualization of the study, and Catherine Bulka, PhD (University of North Carolina at Chapel Hill) for consultation with data analysis. No compensation was provided to any contributors.