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Editor's Choice: Addressing Stigma Through Social Inclusion

This op-ed by Rosalynn Carter was published in the American Journal of Public Health.

A landmark shift in civil rights for people with disabilities occurred with the 1990 enactment of the Americans with Disabilities Act (ADA; Pub. L. No. 101 —336, 104 Stat. 327, enacted July 26, 1990, codified at 42 U.S.C. § 12101). Designed to create consistent and enforceable standards for preventing discrimination against individuals with physical or mental impairments, it called for including people with these health problems in public settings to ensure their full participation in society. Another major step forward, Mental Health: A Report of the Surgeon General, was released in 1999, enlightening the public about the burden of mental disorders, prevention opportunities, recovery possibilities, and the many barriers to quality care that people with mental illnesses face—notably stigma and discrimination. The report remains a guide for the behavioral health field today. (A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services; 1999).

One impetus for the enactment of the original ADA and its subsequent amendments was the intense stigma that existed around epilepsy. Then, as now, stigma caused affected individuals to be denied access to employment, education, housing, and other crucial elements for productive and fulfilling lives. Unfortunately, 22 years after the first passage of the ADA and 13 years after the Surgeon General’s Report, stigma still exists for those with epilepsy, mental illnesses, and other disabilities, hindering their efforts to manage and treat their conditions and be active members of their communities. Some face a double stigma of co-occurring mental illness and chronic disease or mental illness and social disadvantage. The reality of the impact of stigma is solidified by the sobering fact that individuals with serious mental illness die, on average, 25 years earlier than the general population.

Scientific advancements over the past three decades have greatly improved our understanding of the causes, nature, and treatment of many diseases and disabilities, including mental illnesses. Attention to the social determinants of health has led to the identification of risk factors and underlying causes of disadvantage and illness. Technology has made possible unparalleled public access to information so that more and more Americans know that treatments work and are available. Additionally, social networking provides multiple platforms from which advocates and consumers can organize and unite efforts to improve quality of life and address issues such as resiliency and recovery.

Considerable progress has been made in reducing mental health related stigma in the United States with the passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. Furthermore, the increasing focus on integrating primary care and behavioral health services has served to foster inclusion and acceptance of mental health treatment and to reduce stigma and improve access to care. These accomplishments never would have been possible without the commitment, determination, and partnership of those with mental health and substance use disorders, family members, advocates, communities, and policymakers, yet the work is far from done.

A logical tactic in the ongoing battle against stigma is social inclusion, a concept that underlies the ADA. By refocusing public attention on the resiliency and strengths of those with mental illnesses and substance abuse disorders, we can create a culture of social inclusion, which promotes services and policies that help those who need them lead more meaningful lives. This shift of emphasis should guide how we interact with all individuals where we live, learn, work, and play so that everyone has the opportunity to reach their full potential.

In this theme issue on mental illness stigma, public health professionals and researchers recognize that now is the time for the enactment of health policies and programs to ensure that all people can share in life at every level. In that regard, many of the authors recommend action necessary for reducing stigma through advocacy efforts, public awareness campaigns, primary care initiatives, research, and policy. Furthermore, a number of contributors highlight the personal challenges associated with mental illness stigma and important details of their own experiences.

In the past few decades, the mental health community has accomplished much through tenacity. The same dedication that has brought us this far must be applied to decreasing stigma and promoting social inclusion in its place. It will require a devoted, concentrated effort, but we know from past successes that by working together we can achieve great things. 

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