Why is It Important to Elevate the Stigma

Why is It Important to Elevate the Stigma.

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Contents

Advice strategies to counter stigma and better mental health and substance use disorder policy

Emma McGinty

Johns Hopkins University Bloomberg School of Public Wellness Ringgold standard establishment – Section of Wellness Policy and Management, Baltimore, Maryland. Johns Hopkins Academy Bloomberg Schoolhouse of Public Health Ringgold standard institution – Section of Mental Wellness, Baltimore, Maryland

Bernice Pescosolido

Indiana University

Alene Kennedy-Hendricks

Johns Hopkins Bloomberg School of Public Wellness – Health Policy and Management

Colleen L. Barry

Johns Hopkins Bloomberg Schoolhouse of Public Wellness – Health Policy and Managment

Abstract

Despite high burden and poor rates of treatment, public support for allocating resources to improving mental affliction and substance use disorder treatment is low. A growing body of enquiry suggests that effective policy advice strategies can increase public back up for policies benefitting people with these weather. In October 2015, the Center for Mental Wellness and Habit Policy Research at Johns Hopkins University convened an good forum with the goals of identifying what is currently known about the effectiveness of such policy advice strategies and producing a set of recommendations for time to come inquiry. Key forum conclusions include that communication strategies using personal narratives to engage audiences have the potential to increase public support for policies benefiting those with mental illness or substance utilize disorders. Specifically, narratives combining personal stories with depictions of structural barriers to mental affliction and substance apply disorder handling can increase the public’southward willingness to invest in the treatment system without increasing stigma. Depictions of mental illness and violence also increment the public’s willingness to invest in mental health services, simply are no more constructive than messages about structural barriers to handling and significantly increase public stigma toward people with mental affliction. Futurity inquiry should prioritize development and evaluation of advice strategies to increment public support for evidence-based substance use disorder policies, including harm reduction-oriented policies such every bit needle exchange programs and policies expanding treatment.

Introduction

In spite of the significant societal costs of mental disease and substance utilize disorderone
and well-documented shortcomings of the public handling systems for these conditions, including chronic underfunding and provider shortages,ii–4
less than half of Americans back up allocating additional resources to mental illness and substance apply disorder treatment: in 2016, 42% of Americans reported that they were willing to pay $l more per year in taxes to improve the mental wellness service system.v
In 2013, the most recent data available, 39% of Americans supported increasing government spending on treatment for SUD.half dozen
Other evidence-based policies, for case policies expanding admission to naloxone, a medication that tin be used to reverse the effects of an opioid overdose, are as well supported past fewer than 50% of Americans.7
In policy debates, political actors use messages – disseminated through the news media, advocacy campaigns, political advertising, and other avenues – that they believe volition garner public support for their preferred policy position.8–10
A modest just growing body of research, summarized in this article, uses experimental methods to exam the furnishings of these types of policy communication strategies on the public’s support for mental illness and substance use disorder policies.

In October 2015, the Johns Hopkins Center for Mental Health and Addiction Policy Research convened a policy advice forum in Baltimore, Maryland. The forum brought together 45 leading researchers, clinicians, foundation and authorities representatives, and consumer advocates interested in identifying evidence-based advice strategies to increment public support for policies benefiting people with mental disease or substance employ disorder. The primary goals of the forum, which was initiated and led past the four authors of this manuscript, were to assess what is currently known about how advice strategies influence the public’s support for mental illness and substance use disorder policies and identify priorities for hereafter inquiry. The communication strategies considered at the forum were limited to those with available research evaluating their effects on mental illness and/or substance use disorder policy attitudes. As public stigma directed at people with mental disease/substance use disorders is one fundamental driver of policy back up, forum participants too considered how these strategies influence stigma. Enquiry evaluating the effects of communication strategies on stigma alone, contained of support for policy, was outside the scope of the forum. This article reports the forum’due south conclusions and recommendations. At the forum, researchers presented preliminary results from several ongoing studies. These studies, which are among those discussed in this article, were published later the forum.

The Role of Stigma in Policy Preferences

Mental disease and substance use disorder are among the most stigmatized health atmospheric condition in the The states. Public literacy most behavioral health conditions, including endorsement of the neurobiological causes of MI/SUD, has increased dramatically since such attitudes were offset measured in the 1950s.eleven–13
However, public stigma toward people with these conditions has remained high (Figure ane).6,11,12,14
Holding stigmatizing views virtually people with mental affliction or substance utilise disorder is correlated with lower support for many policies designed to benefit these groups.15–19
Results from a national survey conducted in 2013 showed that stigma toward people with mental illness was associated with decreased back up for insurance parity, a policy aimed at eliminating discriminatory coverage of mental health and substance employ disorder insurance benefits, and for allocating additional government funding to mental health services.fifteen
In a 2014 study, Kennedy-Hendricks and colleagues plant that stigma toward individuals with prescription opioid use disorders was associated with decreased public back up for increasing government spending to better substance use disorder handling and other beneficial policies.17
Stigma is besides correlated with increased support for castigating policies, for case absorbing and prosecuting people who obtain multiple opioid prescriptions from different doctors.17


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Public attitudes about persons with mental illness and substance use disorders, 1996–2013

oneFor methodological details, see Pescosolido BA et al. (2010). “A Disease Like Any Other?” A Decade of Change in Public Reactions to Schizophrenia, Depression, and Alcohol Dependence.
American Journal of Psychiatry,
167, 1321–1330.

iiFor methodological details, see Barry CL et al. (2014). Stigma, Discrimination, Treatment Effectiveness, and Policy: Public Views virtually Drug Addiction and Mental Illness.
Psychiatric Services,
65, 1269–72.

3For methodological details, see Barry CL et al. (2013). After Newtown – Public Opinion on Gun Policy and Mental Affliction.
New England Periodical of Medicine,
368 (1077–1081).

fourFor methodological details, see Kennedy-Hendricks et al. (2016). How is social stigma toward individuals with prescription opioid use disorder associated with public support for punitive and public health-oriented policies?
Psychiatric Services,
In Press.

Importantly, these studies demonstrate a correlation betwixt stigma and support for mental disease and substance use disorder policies, not a causal outcome. Stigma is one of multiple factors influencing the public’southward support for policies;16
equally such, it is not necessarily the case that reducing stigma will increment support for benign mental illness and substance apply disorder policies and decrease support for castigating policies. For example, bourgeois political ideology, with its focus on personal responsibleness and limiting the function of government, is consistently associated with decreased support for mental disease and substance utilize policies that crave resource allotment of additional government funds.fifteen,16
Reducing stigma may non exist plenty to overcome these ideologically driven attitudes in opposition to the utilize of governmental funds for mental disease and substance use disorder services. Communication strategies may also increase public support for policies benefitting people with mental illness or substance use disorders without influencing stigma. Messages that affect audiences’ perceptions of the causes, consequences, and salience of the policy problem can shift policy preferences,8,nine,20–24
potentially without corresponding changes in stigma.

Mental Illness and Substance use Disorder Policy Advice Strategies: Current Testify

Forum participants identified five key findings regarding mental disease and/or substance use disorder policy advice strategies, summarized in
Tabular array i
and discussed below. Every bit four of the five communication strategies identified have been evaluated for both mental illness and substance employ disorder policies, we discuss results for both conditions together. However, forum participants emphasized the importance of considering differences in the effectiveness of policy communication strategies for these two weather. While mental illness and substance use disorders are highly co-morbid and increasingly viewed together as “behavioral wellness atmospheric condition” by clinicians and researchers, the public views them differently. Fewer Americans endorse neurobiological causes of substance utilize disorders every bit opposed to mental affliction, with the quondam more than likely to be viewed as a moral or character failure,12,25
and the public has college levels of stigma toward and lower support for policies benefitting people with substance employ disorders versus mental illness.6,12,26
In our word of findings beneath, nosotros highlight similarities and differences in results for mental disease as opposed to substance utilise disorders.


Table ane

Show-based Mental Illness and Substance Use Disorder Stigma Reduction and Policy Advice Strategies

one. Communication strategies employing sympathetic narratives, or stories that humanize the experiences and struggles of individuals with mental disease or substance use disorder, are a promising technique for reducing stigma and increasing support for beneficial policies.

The testify shows that narratives can increment audiences’ receptivity to messages by enhancing engagement and eliciting emotional responses. A fundamental strength of narratives is their ability to blend stories about individuals with contextual data about policy issues. Past themselves, stories about individuals tin can preclude audiences from understanding the societal causes of policy issues and decrease back up for beneficial public policies.
2. Letters blaming people with mental illness or substance use disorder for their condition subtract the public’southward willingness to help these groups and increment support for castigating policy options.

Public perception that the affected grouping is responsible for the problem they confront can lead to lower support for policies benefiting and higher support for policies punishing that group. In dissimilarity, when the public views the cause of the problem as outside of individual control, they are more likely to back up beneficial policies. Studies show that messages blaming individuals with mental illness and substance utilise disorders for their weather condition are associated with negative emotions including increased anger and decreased pity, increased desire for social distance and acceptance of discrimination, and increased back up for coercive treatment, segregated handling, and other punitive policies.
3. Messages highlighting structural barriers to mental illness and substance utilize disorder treatment tin can raise support for benign policies without increasing stigma.

Studies show that messaging strategies highlighting the structural barriers to treatment such equally inadequate insurance coverage, provider shortages, and lack of availability of evidence-based services tin can increase the public’southward willingness to allocate additional resource to mental disease and substance utilise disorder handling and do non elevate stigma.
iv. Messages emphasizing violence by people with mental illness may increase public support for expanding mental health services, simply such letters are stigmatizing and equally effective alternative strategies exist.

Messages linking mental illness with interpersonal violence increase public stigma toward this group. While such messages may increase public back up for expanding mental health services, non-stigmatizing letters emphasizing structural barriers to mental illness treatment are every bit constructive. To engagement, no experimental studies have examined how depictions of violence by people with substance apply disorders influence public stigma and policy attitudes.
five. Letters focused on treatment effectiveness may reduce mental illness/substance use disorder stigma, only effects on policy preferences are uncertain.

Narratives portraying individuals with untreated and symptomatic mental illness and substance use disorder increase public stigma; compared to these depictions, portrayals of people experiencing successful treatment recovery decrease stigma. Studies suggest that on their own, messages about treatment effectiveness may not increment support for expanding mental illness and substance use disorder treatment, potentially because depictions of individuals successfully accessing services fail to convince the public of the need for treatment expansions. Futurity studies should test narratives combining messages highlighting handling effectiveness messages, which may reduce stigma, with messages about structural barriers to treatment, which appear to increase support for expanded services.

Advice strategies that utilise sympathetic narratives, or stories that humanize the experiences and struggles of individuals with mental illness or substance employ disorder, are a promising technique for reducing stigma and increasing back up for beneficial policies

Policymakers, advocates, and journalists have long used stories most individuals, to illustrate policy problems and potential solutions. Communication research empirically demonstrates the persuasive power of narratives, which blend stories about individuals, or “individual depictions,” with broader contextual information near the problem at hand. Private depictions in the absenteeism of contextual information can prevent audiences from understanding the part of societal drivers of the policy problem and instead blame the individual depicted for the problems he or she faces.30
This is problematic from a policy support perspective given research demonstrating that the public is more than likely to support policies benefiting individuals whose problems are perceived equally stemming from societal causes exterior of individual control rather than policies benefiting individuals who are perceived to exist responsible for causing their ain bug.thirty–32
Narratives aid to overcome this issue by blending engaging stories about individuals with contextual information about the larger social trouble, for instance a narrative that tells a story about a specific individual with drug dependence merely also (a) describes the social and environmental risk factors that contributed to that individual’south condition and (b) places the individual’s story in the larger context of the problem of drug dependence in the Usa. Narratives have been shown to heighten audiences’ appointment with the issue existence described and elicit emotional responses, both of which may enhance receptivity to the narrative’south message.27–29
The limited existing research suggests that narratives, are a promising strategy for improving support for both mental illness and substance use disorder treatment policies.five,33,34

Letters blaming people with mental illness or substance utilise disorder for their condition decrease the public’s willingness to help these groups and increment support for punitive policy options

Attribution theory suggests that when considering the causes of social problems, people typically exaggerate the role of individual responsibility and underestimate the importance of factors outside of individuals’ command, such every bit community resources and environmental exposures.35,36
This “fundamental attribution bias” can influence the public’southward policy preferences. Public perception that the affected group is responsible for the problem they face tin can lead to lower support for policies benefiting and higher support for policies punishing this affected group. In contrast, when the public views the cause of the trouble every bit wholly or mostly exterior of individual control, they are more likely to support policies benefiting the affected group. Based on existing inquiry, this concept appears relevant for both mental illness and substance use disorder.

Weiner and Corrigan have demonstrated that blaming individuals with mental illness for their status is associated with negative emotions and attitudes including increased acrimony, decreased compassion, and back up for mandatory and segregated treatment.37–39
It is of import to note that while mandatory treatment policies such as assisted outpatient handling are viewed as castigating by some stakeholders, who perceive such policies as restricting civil liberties,twoscore,41
other groups view policies expanding mandatory treatment as a beneficial arroyo that helps people with mental affliction and substance use disorder go needed handling.42,43
In the substance employ disorder context, an assay of 2013 national survey information found that attributing responsibility for prescription opioid use disorders to the people experiencing such disorders was correlated with increased desire for social distance, acceptance of discrimination, support for punitive policies – for case arresting individuals who obtain multiple opioid prescriptions from dissimilar doctors – and lower back up for increasing authorities spending on substance use treatment.17

While these studies suggest that communication strategies blaming people with a mental illness or substance employ disorder for their condition can take detrimental effects on stigma and policy attitudes, increasing the degree to which the public attributes responsibility for these weather to factors exterior of affected individuals’ command may be insufficient to reduce stigma and increase support for beneficial policies. In the latter half of the 20th century, many consumer advocates believed that educating the public on the neurobiological causes of mental illness was the key to stigma reduction.12
This idea informed the pattern of communication campaigns: in the 1990s and early on 2000s, the predominant stigma reduction strategy in the US was the “Disease Like Any Other” campaign led by the National Alliance on Mental Illness (NAMI), which equated mental illnesses and substance use disorders with other biological atmospheric condition similar diabetes.12
As a event of this and other pedagogy efforts, Americans’ endorsement of the neurobiological causes of both atmospheric condition increased from 1996 to 2006, only corresponding decreases in public stigma toward individuals with these conditions did not occur.12
Some evidence suggests that endorsement of the biological illness model may
increase
stigma, potentially equally a result of increased perceptions of the permanence – and related pessimism regarding the potential for recovery – of mental illness and substance apply disorder.44,45

The public endorses multiple causes of mental illness and substance use disorders, e.1000. some Americans recognize a neurobiological component of substance utilize disorder etiology and too endorse poor character equally a cause of the condition.12,46
Information technology is therefore possible that in order to subtract stigma, increasing public endorsement of causal factors outside of the control of individuals with mental affliction and substance use disorders, like neurobiological causes, is, solitary, bereft; nosotros may besides demand to decrease endorsement of causal factors inside affected individuals’ control. While endorsement of neurobiological causes increased from 1996–2006, the proportion of Americans who viewed poor graphic symbol as a crusade of schizophrenia and major depression remained unchanged (31% and 32% in 2006) and the percent of Us adults attributing booze use disorder to poor character increased, from 49% in 1996 to 65% in 2006.12
Increased neurobiological endorsement may increase public back up for expanding mental wellness and substance use disorder treatment independent of stigma, simply this relationship has not been directly tested. National survey results show a 9% increase in public support for increasing regime spending on mental wellness services from 1996–2013 (50% in 1996, 59% in 2013),16,47
but it is unclear whether this increase is attributable to parallel increases in endorsement of neurobiological causes of mental affliction during this period. Further, these survey results should be interpreted with caution: the 2013 survey was conducted in the month following the mass shooting at Sandy Hook Elementary Schoolhouse in Newtown, Connecticut, by an private widely believed to take a serious mental illness. This shooting prompted a national dialogue on mental illness and may have led to a temporary increase in the proportion of Americans supporting increased investment in mental health handling.48,49

Letters highlighting structural barriers to mental illness and substance utilize disorder treatment can raise support for beneficial policies without increasing stigma

Messaging strategies that draw attending to the societal causes of social bug have the potential to counter the public’due south propensity to form opinions consistent with fundamental attribution bias theory. Advice strategies emphasizing structural barriers to handling such every bit inadequate insurance coverage, provider shortages, and lack of availability of evidence-based services like supportive employment are one of the most common messaging strategies used by consumer advancement groups hoping to garner public support for improving the mental affliction and substance use disorder service systems.fifty–52
This strategy emphasizes the structural shortcomings that contribute to poor outcomes among people with mental illness or substance use disorders and are direct addressable through public policy.

A limited body of experimental research suggests that this approach holds hope for improving support for public policies benefiting those with a mental illness or substance use disorder. A randomized message framing experiment conducted in 2016 showed that compared to a control arm, a curt narrative describing an private with schizophrenia who faces multiple structural barriers to treatment, including inadequate insurance coverage and provider shortages, increased the public’s willingness to pay taxes to meliorate the public mental wellness service organisation and their support for expanding a range of service options, including customs-based outpatient treatment, supportive employment, and long-term hospitalization.5

In a 2014 study conducted using a national online survey console, Kennedy-Hendricks and colleagues tested the effect of a cursory written narrative describing the barriers to accessing bear witness-based opioid use disorder treatment faced by a low-income pregnant woman, such as a long waiting list for methadone handling.33
Compared to both the control arm and a narrative describing the aforementioned woman without mentioning barriers to treatment, messages virtually barriers to treatment did not change social distance attitudes but were associated with increased feelings of sympathy and compassion, too every bit greater support for beneficial policies including expanding Medicaid health insurance benefits to comprehend prescription opioid use disorder handling.33
Barriers to treatment messages were also associated with decreased support for punitive policies, including a policy requiring health care providers to study significant women with opioid employ disorders to the state’s child welfare agency.33

Messages emphasizing violence past people with mental illness may increase public back up for expanding mental wellness services, merely such letters are stigmatizing and equally effective alternative strategies exist

Multiple experimental studies accept shown that messages emphasizing acts of violence past people with mental illness increase public stigma toward this group.v,53–56
Until recently, less was known almost how violence-focused letters influence back up for expanding mental health treatment. In the previously mentioned experimental study of a narrative describing structural barriers to treatment faced past an individual with schizophrenia, a version of the narrative was tested where the same individual went on to commit a public shooting.5
Different the narrative describing barriers to care without violence, this narrative increased stigma compared to the command grouping. The narratives describing barriers to intendance with and without violence were equally effective at increasing the public’s willingness to pay additional taxes to ameliorate mental health services and their support for expanding all of the mental service options measured. This suggests that letters about barriers to intendance, opposed to the delineation of violence, collection public back up for allocating additional resources to expand public mental wellness services.five
This study congenital on a prior written report using a college student sample in which Corrigan et al. establish that, compared to a control group, messages linking mental affliction with violence delivered in a confront-to-face educational intervention elevated stigma but did not increase willingness to allocate resources to psychiatric rehabilitation or mandated care.54

To our knowledge, no experimental inquiry on the effects of communication strategies linking substance utilize disorder with violence have been conducted. This topic warrants future study given survey research showing that the public perceives people with substance employ disorder as more likely to be violent than those with MI.12,46

Messages focused on treatment effectiveness may reduce mental disease/substance employ disorder stigma, but effects on policy preferences are uncertain

Enquiry has demonstrated that public stigma is tied, in part, to the symptoms and behaviors associated with untreated mental illness/substance use disorder, particularly positive psychotic symptoms and related behaviors like talking to oneself and reject in personal hygiene.12,46,57
Express existing research suggests that communication strategies focused on disseminating messages about successful treatment and recovery – a strategy credited with major reductions in the public stigma surrounding HIV/AIDS58
– may reduce the public stigma surrounding both mental illness and substance use disorder, though in the experimental studies conducted to date such messages have not influenced public support for mental affliction or substance use disorder policy.

Using data from a phone survey of a nationally representative sample of youth aged xiv–22, Romer and colleagues constitute that youth reported less stigma toward an private their own historic period described as having treated versus untreated depression.59
In a 2013 experiment using a nationally representative online survey panel, McGinty et al. found that short narratives describing individuals experiencing successful treatment for and recovery from schizophrenia, prescription opioid use disorder, and heroin employ disorder reduced stigma compared to depictions of individuals with the aforementioned untreated and symptomatic conditions.57
Comparing depictions of successfully treated versus untreated mental affliction or substance use disorder is a valid comparison, given that such portrayals are oftentimes pitted against one another policy debates. However, when measures of stigma are compared between respondents exposed to portrayals of successful handling versus a control group of respondents exposed to no messages, stigma reduction effects largely disappear.5,57

Two large national experiments have shown that, compared to a control arm, depictions of successful treatment and recovery practise not increase public back up for allocating resources to expanded mental illness and substance use disorder services.5,57
Given studies showing that narratives describing barriers to treatment increase back up for expanding mental illness/substance apply disorder services,5,33
narratives depicting successful treatment, which bear witness people with mental illness or substance apply disorders accessing and benefiting from services, may fail to convince audiences of the need to improve the existing handling organization.

Future Research

Forum participants identified 5 priorities for new research in this surface area, summarized in
Table 2
and discussed beneath. The first two inquiry priorities are substance use disorder-specific, and the final three priorities apply to both mental disease and substance use disorders.


Table 2

Proposed Mental Illness and Substance Apply Disorder Stigma Reduction and Policy Communication Research Priorities

i. Increasing public support for expanding prove-based substance use disorder treatment.

Given the high prevalence and low treatment rates of substance use disorders in the US, development of communication strategies to increment support for evidence-based policies to foreclose and treatment substance apply disorders is a priority. To succeed, such strategies demand to overcome the dominant public perception that people with substance use disorders are to blame for and in control of their condition.
2. Assessing communication strategies to increase public back up for harm reduction approaches.

Harm reduction strategies aim to reduce negative consequences associated with drug use. Evidence-based harm reduction strategies such as needle exchanges, rubber injection facilities, and naloxone administration have been shown to decrease overdose, decrease transmission of HIV and other diseases, and increase rates of treatment. With the exception of naloxone, however, these strategies accept not been widely implemented in the US, in function due to low public support for policies designed to reduce the negative consequences of drug utilize without eliminating drug use itself.
3. Disentangling the function of race and socioeconomic status in public stigma and mental illness and substance employ disorder policy support.

Mental illness and substance use disorders are linked in the public’southward mind with racial, ethnic, and class characteristics that independently engender stigmatizing attitudes. Ane of the challenges of overcoming public stigma toward people with mental illness and substance use disorders and garnering public support for policies benefiting these groups is our lack of understanding regarding how much stigma and support for beneficial policies is related to mental illness and substance use disorders themselves versus race, class, or other stigmatizing characteristics.
4. Understanding policy feedback – how practice perceptions of existing mental illness and substance use disorder policies influence public stigma and support for farther policy enactment?

The policy feedback literature shows that enactment of public policies can atomic number 82 to shifts in public perceptions of the worthiness of the population targeted past the policy and shift political ability by creating new constituencies. For example, Medicare is widely credited with increasing public perceptions of older adults as deserving of pregnant public investment and creating a powerful interest group of beneficiaries. In the mental illness and substance use disorder context, it is particularly important to empathize how the growing number of policies designed to ensure equity in how our medical and insurance sectors approach mental illness and substance use disorders relative to other medical conditions, like insurance parity, and how shifts away from punitive drug control policy and toward increased accent on prevention and treatment influence public attitudes.
v. Testing the furnishings of rights-oriented messages on public stigma and mental disease/substance use disorder policy preferences.

The major mental illness and substance use disorder policy initiatives of the concluding century, including deinstitutionalization, passage of the Americans with Disabilities Act, and the federal insurance parity constabulary have shared a civil rights orientation, seeking to prohibit bigotry on the footing of mental affliction or substance utilize. To date, all the same, niggling is known about how rights-oriented letters influence public stigma and support for mental health and substance use disorder policies. Rights-oriented letters have most unremarkably been applied to mental illness, but the potential for such letters to shift public attitudes about substance apply disorder policy issues should as well be considered.

Increasing public support for expanding bear witness-based substance use disorder treatment

Given the high prevalence and depression rates of treatment for substance use disorder in the US, advice strategies should aim to improve support for policies that expand access to evidence-based handling for this group. To succeed, such strategies may demand to overcome the dominant public perception that people with substance use disorder have a high caste of control over their substance apply behaviors and are therefore able to finish using substances without medical and/or psychosocial treatment.6,17,25
While bachelor evidence suggests that communication strategies emphasizing the neurobiological causes of mental disease and substance use disorders do not subtract stigma,60
they may increment support for expanding handling independent of stigma. Advice strategies designed to increment the public’s understanding of substance use disorder handling options and the efficacy of those options as a ways to increasing support for expanded substance utilise disorder treatment should be explored. A 2015 public opinion survey establish that only 19% of Americans surveyed thought methadone – the goal standard for opioid use disorder handling61
– was the best fashion to treat heroin dependence, instead endorsing strategies like Narcotics Bearding that involve going completely drug complimentary.62
This suggests that communication strategies dispelling myths and emphasizing the efficacy of medication-assisted treatments like methadone may increase public support for expanded funding and delivery of such treatments.

Assessing communication strategies to increase public support for harm reduction approaches

The term “harm reduction” refers to strategies aimed at reducing negative consequences associated with drug use.63
Harm reduction strategies such as syringe commutation programs and safe consumption sites take been shown to reduce HIV transmission and increase appointment with drug treatment and other social services.64,65
Another harm reduction strategy, assistants of naloxone, can save lives by reversing the course of opioid overdose.66
Harm reduction strategies have not been widely implemented in the U.s.a., in part due to low public support for policies designed to reduce the negative consequences of drug utilise without eliminating drug use itself.67
However, the ongoing opioid crisis may exist increasing Americans’ openness to this type of strategy. Equally of Nov 2016, 45 The states states accept passed policies designed to increase access to naloxone.68

While a window of opportunity for enactment of impairment reduction approaches may exist opening, to date little is known about which communication strategies increase public support for such strategies. To our knowledge, but one message framing experiment has focused on damage reduction. In a 2015 written report, Bachhuber and colleagues tested a narrative describing a immature adult female who died from a prescription opioid overdose.34
The narrative combined a sympathetic clarification of the woman with educational messages about naloxone, including messages refuting the idea that use of naloxone encourages people to continue using prescription opioids by providing a “safe net” from overdose.34
The narrative went on to counter contend that, in fact, many people whose lives are saved past naloxone encounter it as a wake-up call and enter treatment (a point supported by research).34
Compared to a command arm, this narrative raised public support for policies that would railroad train first responders to employ naloxone, provide naloxone to friends and family members of people at risk of opioid overdose, pass laws to protect people if they call for medical assistance for an opioid overdose, and laissez passer laws to legally protect people who administer naloxone.34
This study suggests that a sympathetic narrative combined with educational letters virtually impairment reduction approaches, including messages that refute mutual misconceptions about that approach, may concur promise for increasing public support for prove-based harm reduction strategies.

Disentangling the role of race and socioeconomic condition in public stigma and mental illness and substance use disorder policy back up

Mental affliction and substance utilise disorder are linked in the public psyche with racial, indigenous, and course characteristics that independently engender stigmatizing attitudes.25,69,70
Thus, 1 of the challenges with overcoming public stigma toward people with mental affliction or substance disorders and garnering public support for beneficial policies is our lack of understanding regarding how much stigma and reluctance to support beneficial policies is related to mental illness and substance use, and how much is related race, class, or other stigmatizing characteristics. This outcome is frequently highlighted in the context of the current prescription opioid epidemic. Opinion leaders affirm that considering the current epidemic affects whites living in not-urban areas, different the prior heroin and crack cocaine epidemics, which predominantly affected depression-income, urban communities of color,71,72
policy responses have shifted toward a more helping and less punitive approach.73–75

Limited experimental research has examined these issues. In a nationally representative experiment conducted in 2014, Kennedy-Hendricks et al. tested two versions of a narrative depicting a pregnant woman with prescription opioid apply disorder: versions portraying her every bit having depression versus high socioeconomic status.33
Compared to the depression socioeconomic status portrayal, respondents who read the high socioeconomic condition narrative were less likely to blame people with prescription opioid apply disorders for their status and less probable to support punitive policies targeting pregnant women with prescription opioid use disorders.33
Farther piece of work to empathize how stigma and policy attitudes related to race and course interact with attitudes well-nigh substance use disorder is needed, with consideration of differences across specific substance use disorders. For example, because crack cocaine has long been associated with urban, poor, African-American communities, stigma and policy attitudes related to race and form may interact with public attitudes almost cocaine apply disorder differently than other conditions similar opioid utilize disorder or cannabis utilize disorder. Given the need for policy solutions to address significant racial disparities in drug-related arrest, prosecution, and incarceration in the United states of america, this area of research is especially important for illicit drugs. No prior studies take examined these issues in the context of mental affliction. Given significant racial and ethnic disparities in diagnosis of conduct and oppositional defiant disorder, i avenue for future research might consider how public attitudes well-nigh race influence the effectiveness of communication strategies designed to improve public support for allocating resources to services for children with these atmospheric condition.

Understanding policy feedback – how practise perceptions of existing mental illness and substance use disorder policies influence public stigma and support for further policy enactment?

The past decade has witnessed major changes at the national and country levels in the mental illness and substance apply disorder policy mural, including but not limited to passage of the federal Mental Wellness Parity and Addiction Equity Human activity;76
the multiple mental illness and substance use disorder provisions of the Affordable Intendance Human action;77
the Function of National Drug Command Policy’southward allotment of significant new resources to expand medication-assisted opioid treatment;78
and state-level legalization of marijuana for medical and/or recreational use.79
Currently, very little is known regarding how public perceptions of these policies ‘feedback’ into the public’due south stigma and policy attitudes. The policy feedback literature suggests that enactment of public policies can lead to shifts in public perceptions of the worthiness of the population targeted by the policy and shift political power by creating new constituencies.80
These factors, along with perceptions of the effectiveness of these public policies, tin can also influence public attitudes regarding enactment of new public policies. For example, over the past sixty years, deinstitutionalization of state psychiatric hospitals and delivery laws emphasizing civil liberties over medical need take contributed to high rates of homelessness and criminal justice interest amongst people with serious MI.2,81
Mental illness policy scholars have asserted that these policies increased public stigma – because the laws increased the likelihood that the general public is exposed, in-person or through the news media, to negative examples of people with conditions like schizophrenia – and galvanized state efforts to enact assisted outpatient handling laws.2,82–86

Communication research focused on policy feedback is of particular interest in two domains. Starting time, inquiry should consider how the growing number of policies designed to ensure equity in how the United states health insurance and healthcare delivery sectors approach mental illness and substance apply disorder relative to other medical conditions – including insurance parity regulations and efforts to improve integration in the financing and delivery of mental illness/substance use disorder and general medical services – influence public stigma and support for other mental illness and substance apply policies. 2nd, future research should assess how letters emphasizing shifts away from castigating policy approaches influence public stigma and policy preferences. For case, the prescription opioid epidemic has contributed to a shift away from punitive, criminal justice-oriented drug control and toward an increased public wellness emphasis on prevention and treatment.78
To appointment, trivial is known most how this type of policy shift influences public attitudes most mental illness and substance use, and whether policy feedback operates differently for mental disease versus substance utilize disorder. Hereafter policy feedback research should also consider how the policies of involvement influence cocky- and structural-stigma, and how those dimensions of stigma in plough influence public stigma and back up for policy.

Testing the effects of rights-oriented messages on public stigma and mental disease and substance utilize disorder policy preferences

The U.s.a. consumer mental health movement has long framed its mission and values in terms of civil rights and citizenship. The major mental illness and substance utilise policies of the final century, including deinstitutionalization, passage of the Americans with Disabilities Act, and the federal insurance parity police force have shared this anti-discrimination, full-citizenship orientation, seeking to prohibit discrimination on the basis of mental illness and substance use disorder and ensure that people with these atmospheric condition have the same rights as all other citizens. To our noesis, no large-scale experimental studies have tested how messages framing public policies as designed to protect the rights of people with mental affliction or substance utilize disorder influence public stigma and policy support. In improver, petty is known regarding if and how rights-oriented messages, which have most commonly been practical to MI, tin exist used to shift public attitudes near substance utilise disorder issues.

Finally, beyond approaches to testing mental illness and substance use disorder policy communication strategies like those discussed above, futurity enquiry should exam the persuasiveness of letters in contest. Most current experimental enquiry compares attitudes amidst respondents exposed to a unmarried messaging strategy to attitudes amidst respondents assigned to a control arm. In reality, mental illness and substance apply disorder policy debates betrayal the public to multiple competing messages simultaneously. In particular, future research on competitive framing in the mental illness and substance use disorder policy context should examine inoculation and pre-emptive refutation strategies. A growing body of advice research suggests that inoculation strategies, which present audiences with weakened forms of competing messages, help audiences to develop counter-arguments to showtime future competing messages. Inoculation strategies oft include refutational letters – similar the message, tested by Bachhuber et al, which refuted the idea that naloxone availability encourages connected opioid use – which explicitly betoken out the flaws in competing arguments.

Future inquiry should also appraise the elapsing of effects of mental illness and substance apply disorder policy communication strategies. Most existing experiments have tested effects at a single indicate in fourth dimension, immediately following bulletin exposure. In ane exception, Niederdeppe and colleagues found that compared to inoculation letters refuting pharmaceutical industry arguments against policies to curb prescription opioid misuse, a narrative combining a description of a adult female experiencing prescription opioid use disorder with arguments in favor of the policies had stronger effects on respondents’ attitudes over time.29

Future research should as well consider how communication strategies influence support for beneficial mental illness and substance utilize disorder policies amongst specific stakeholders, including policymakers and interest groups. While public stance is a key commuter of policy development and policies with strong public support are most likely to be enacted,87
support from policymakers and interest groups – opposed to the general public – is the impetus for some mental illness/substance use disorder policies. More half of Americans are not aware of the provisions of the Mental Health and Addiction Parity Act,88
suggesting that the defended efforts of consumer advocacy groups and leading political proponents, like erstwhile Congressman Patrick Kennedy, drove parity enactment.76
Similarly, public opinion may not have played a major function in Congress’s decision to laissez passer the uncontroversial 2016 21st
Century Cures Act, which received lilliputian public debate and includes provisions to aggrandize mental illness and substance utilize disorder handling. It is worth noting, however, that public need for solutions to the opioid epidemic is high,89
and expanded opioid utilise disorder handling was a key component of the 21st
Century Cures law.xc

Conclusion

Mental illness and substance use disorder policy advice inquiry is an emerging field and the show described in this manuscript is based on a relatively small number of published studies. All the same, a growing trunk of research demonstrates that policy advice strategies can increment support for policies that benefit people with mental disease or substance utilize disorders. Of the communication strategies identified, strategies that use personal narratives to engage audiences and highlight structural barriers to treatment are particularly promising; the current inquiry suggests that such strategies tin can increase the public’s support for policies benefiting people with mental illness or substance utilize disorders without increasing stigma.5,33
While advice strategies linking mental affliction with violence increment Americans’ willingness to pay taxes to meliorate the public mental health arrangement, these letters are no more effective than messages focused on structural barriers and drag stigma.five
Thus, barriers-to-treatment messages offer advocates and policymakers interested in promoting policies to strengthen the handling system a compelling alternative to stigmatizing violence-focused messaging. In the context of the high burden of the substance use disorders in the US, in particular the ongoing opioid epidemic, it is disquisitional to develop new advice strategies capable of increasing public support for evidence-based public health and medical policies to forestall and treat substance use disorder-related morbidity and mortality, including harm reduction policies, such equally policies creating or expanding safe consumption sites and syringe exchange programs, and policies to increase medication-assisted opioid apply disorder treatment.

Acknowledgments

[Blinded for Review] gratefully acknowledges support from the National Institute of Mental Health (NIMH), K01MH106631

Contributor Data

Emma McGinty,


Johns Hopkins Academy Bloomberg School of Public Wellness Ringgold standard institution – Section of Health Policy and Management, Baltimore, Maryland. Johns Hopkins University Bloomberg School of Public Health Ringgold standard institution – Department of Mental Health, Baltimore, Maryland.

Bernice Pescosolido,


Indiana University.

Alene Kennedy-Hendricks,


Johns Hopkins Bloomberg Schoolhouse of Public Health – Wellness Policy and Management.

Colleen L. Barry,


Johns Hopkins Bloomberg School of Public Wellness – Health Policy and Managment.

References

ane.
Roehrig C. Mental Disorders Height The List Of The Most Costly Conditions In The United States: $201 Billion.

Health Affairs.
2016;35(six):1130–1135.

[PubMed]
[Google Scholar]

two.
Frank RG, Glied SA.
Amend just not well: Mental health policy in the United states of america since 1950.
Baltimore: Johns Hopkins Academy Press; 2006.
[Google Scholar]

three.
Cummings JR, Wen H, Druss BG. Improving access to mental health services for youth in the United States.

JAMA : the periodical of the American Medical Clan.
2013;309(6):553–554.

[PMC free commodity]
[PubMed]
[Google Scholar]

4.
Dick AW, Pacula RL, Gordon AJ, et al. Increasing Potential Admission to Opioid Agonist Treatment in Usa Handling Shortage Areas.

Wellness affairs (Project Hope)
2015;34(6):1028.

[PMC costless article]
[PubMed]
[Google Scholar]

five.
McGinty EE, Pescosolido BA, Goldman HH, Barry CL. Communicating virtually Mental Disease and Violence: Balancing Increased Support for Services and Stigma.

Journal of Health Politics, Policy and Constabulary.
2017

In Press.
[Google Scholar]

6.
Barry CL, McGinty EE, Pescosolido BA, Goldman HH. Stigma, discrimination, treatment effectiveness, and policy: public views about drug addiction and mental disease.

Psychiatric services (Washington, DC)
2014 Oct;65(10):1269–1272.

[PMC free article]
[PubMed]
[Google Scholar]

7.
Barry CL, Kennedy-Hendricks A, Gollust SE, et al. Understanding Americans’ views on opioid pain reliever abuse.

Habit.
2016 January;111(one):85–93.

[PMC gratuitous article]
[PubMed]
[Google Scholar]

8.
Entman RM. Framing: Toward Description of a Fractured Prototype.

Journal of Communication.
1993;43(4):51–58.

[Google Scholar]

9.
Chong D, Druckman JN. Framing Theory.

Almanac Review of Political Science.
2007;ten(1):103–126.

[Google Scholar]

x.
Graber DA, Dunaway J.
Mass media and American politics.
CQ Press; 2014.
[Google Scholar]

11.
Phelan JC, Link BG, Stueve A, Pescosolido BA. Public Conceptions of Mental Affliction in 1950 and 1996: What Is Mental Illness and Is It to be Feared?

Journal of Wellness and Social Beliefs.
2000;41(2):188–207.

[Google Scholar]

12.
Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG. “A disease like any other”? A decade of alter in public reactions to schizophrenia, depression, and alcohol dependence.

Am J Psychiatry.
2010 November;167(11):1321–1330.

[PMC gratis article]
[PubMed]
[Google Scholar]

13.
Pescosolido BA. The Public Stigma of Mental Illness: What Do we Think; What Exercise We Know; What Can We Prove?

Journal of Health and Social Behavior.
2013;54(ane):one–21.

[PMC free commodity]
[PubMed]
[Google Scholar]

14.
Barry CL, McGinty EE, Vernick JS, Webster DW. Later on Newtown—public opinion on gun policy and mental illness.

New England periodical of medicine.
2013;368(12):1077–1081.

[PubMed]
[Google Scholar]

15.
Barry CL, McGinty EE. Stigma and public support for parity and regime spending on mental health: a 2013 national opinion survey.

Psychiatric services (Washington, DC)
2014 Oct;65(x):1265–1268.

[PMC free article]
[PubMed]
[Google Scholar]

xvi.
McSween JL. The role of group interest, identity, and stigma in determining mental health policy preferences.

J Health Polit Policy Police force.
2002 Oct;27(5):773–800.

[PubMed]
[Google Scholar]

17.
Kennedy-Hendricks A, CLB, Ensminger ME, Chisolm MS, EEM How is social stigma toward individuals with prescription opioid apply disorder associated with public back up for punitive and public health-oriented policies?

Psychiatric Services.
2016

In Press. [PubMed]
[Google Scholar]

18.
Sikorski C, Luppa M, Kaiser M, et al. The stigma of obesity in the general public and its implications for public health-a systematic review.

BMC public wellness.
2011;11(1):1.

[PMC free article]
[PubMed]
[Google Scholar]

xix.
Herek GM, Capitanio JP, Widaman KF. Stigma, social adventure, and health policy: public attitudes toward HIV surveillance policies and the social structure of illness.

Health Psychology.
2003;22(5):533.

[PubMed]
[Google Scholar]

20.
Haidt J.
The righteous heed: Why skillful people are divided by politics and religion.
Vintage; 2012.
[Google Scholar]

21.
Nelson TE, Garst J. Values-based political messages and persuasion: relationships among speaker, recipient, and evoked values.

Polit Psychol.
2005;26(four):489–515.

[Google Scholar]

22.
Gross K. Framing Persuasive Appeals: Episodic and Thematic Framing, Emotional Response, and Policy Opinion.

Political Psychology.
2008;29(2)

[Google Scholar]

23.
Iyengar Southward.
Is anyone responsible? How tv set frames political issues.
London: University of Chicago Press; 1991.
[Google Scholar]

24.
Scannell L, Gifford R. Personally relevant climatic change the role of place attachment and local versus global message framing in engagement.

Environment and Behavior.
2013;45(ane):60–85.

[Google Scholar]

25.
Morone JA. Enemies of the People: The Moral Dimension to Public Wellness.

Journal of Health Politics, Policy and Law.
1997 Aug i;22(four):993–1020.

[PubMed]
[Google Scholar]

26.
Corrigan Prisoner of war, Kuwabara SA, O’Shaughnessy J. The public stigma of mental affliction and drug addiction findings from a stratified random sample.

Journal of Social Piece of work.
2009;9(2):139–147.

[Google Scholar]

27.
Frank LB, White potato ST, Chatterjee JS, Moran MB, Baezconde-Garbanati L. Telling stories, saving lives: creating narrative wellness messages.

Wellness advice.
2015;30(ii):154–163.

[PMC complimentary commodity]
[PubMed]
[Google Scholar]

28.
Murphy ST, Frank LB, Chatterjee JS, Baezconde-Garbanati L. Narrative versus nonnarrative: The role of identification, transportation, and emotion in reducing health disparities.

Periodical of Communication.
2013;63(ane):116–137.

[PMC free article]
[PubMed]
[Google Scholar]

29.
Niederdeppe J, Heley K, Barry CL. Inoculation and Narrative Strategies in Competitive Framing of Iii Health Policy Issues.

Journal of Communication.
2015;65(5):838–862.

[Google Scholar]

30.
Iyengar Southward. Framing responsibility for political bug: the case of poverty.

Political Behavior.
1990;12(1):19–xl.

[Google Scholar]

31.
Iyengar Due south. Framing Responsibility for Political Bug.

Annals of the American Academy of Political and Social Science.
1996;546:59–70.

[Google Scholar]

32.
Iyengar S, Kinder DR.
News that Matters: Television and American Opinion.
University of Chicago Press; Chicago IL: 1987.
[Google Scholar]

33.
Kennedy-Hendricks A, McGinty EE, Barry CL. Effects of Competing Narratives on Public Perceptions of Opioid Pain Reliever Addiction during Pregnancy.

Journal of Health Politics, Policy and Police force.
2016:3632230.

[PubMed]
[Google Scholar]

34.
Bachhuber MA, McGinty EE, Kennedy-Hendricks A, Niederdeppe J, Barry CL. Messaging to Increment Public Support for Naloxone Distribution Policies in the United States: Results from a Randomized Survey Experiment.

PloS ane.
2015;10(7):e0130050.

[PMC free article]
[PubMed]
[Google Scholar]

35.
Manusov 5, Spitzberg B.

Attribution theory.
2008

na.
[Google Scholar]

36.
Weiner B. On sin versus sickness: A theory of perceived responsibleness and social motivation.

American Psychologist.
1993;48(9):957.

[PubMed]
[Google Scholar]

37.
Corrigan P, Markowitz FE, Watson A, Rowan D, Kubiak MA. An attribution model of public discrimination towards persons with mental disease.

Periodical of health and Social Behavior.
2003:162–179.

[PubMed]
[Google Scholar]

38.
Corrigan PW, Rowan D, Dark-green A, et al. Challenging Two Mental Illness Stigmas: Personal Responsibility and Dangerousness.

Schizophrenia Bulletin.
2002–2002 January 1;28(2):293–309.

[PubMed]
[Google Scholar]

39.
Weiner B, Perry RP, Magnusson J. An attributional analysis of reactions to stigmas.

Periodical of personality and social psychology.
1988;55(v):738.

[PubMed]
[Google Scholar]

44.
Mehta S, Farina A. Is existence “sick” actually better? Effect of the illness view of mental disorder on stigma.

Periodical of Social and Clinical psychology.
1997;sixteen(4):405–419.

[Google Scholar]

45.
Schnittker J. An uncertain revolution: Why the ascent of a genetic model of mental illness has not increased tolerance.

Social scientific discipline & medicine.
2008;67(9):1370–1381.

[PubMed]
[Google Scholar]

46.
Link BG, Phelan JC, Bresnahan Grand, Stueve A, Pescosolido BA. Public conceptions of mental illness: labels, causes, dangerousness, and social distance.

American journal of public health.
1999 Sep;89(9):1328–1333.

[PMC gratuitous article]
[PubMed]
[Google Scholar]

47.
Barry CL, McGinty EE, Vernick JS, Webster DW. Subsequently Newtown – Public Opinion on Gun Policy and Mental Illness.

New England Journal of Medicine.
2013;(368):1077–1081.

[PubMed]
[Google Scholar]

48.
McGinty EE, Webster DW, Jarlenski M, Barry CL. News media framing of serious mental illness and gun violence in the The states, 1997–2012.

American Journal of Public Health.
2014;104(xx):406–413.

[PMC free article]
[PubMed]
[Google Scholar]

49.
Glied S, Frank RG. Mental illness and violence: lessons from the evidence.

American journal of public health.
2014 Feb;104(2):e5–6.

[PMC free article]
[PubMed]
[Google Scholar]

53.
Corrigan Pow, Powell KJ, Michaels PJ. The furnishings of news stories on the stigma of mental disease.

The Journal of nervous and mental disease.
2013;201(3):179–182.

[PubMed]
[Google Scholar]

54.
Corrigan Pow, Watson Air-conditioning, Warpinski AC, Gracia Yard. Implications of Educating the Public on Mental Disease, Violence, and Stigma.

Psychiatric services (Washington, DC)
2004 May 1;55(5):577–580.

[PubMed]
[Google Scholar]

55.
Angermeyer MC, Matschinger H. The result of violent attacks past schizophrenic persons on the attitude of the public towards the mentally ill.

Social Science & Medicine.
1996;43(12):1721–1728.

[PubMed]
[Google Scholar]

56.
McGinty EE, Webster DW, Barry CL. Effects of news media messages well-nigh mass shootings on attitudes toward persons with serious mental affliction and public support for gun policies.

American Journal of Psychiatry.
2013;170:494–501.

[PubMed]
[Google Scholar]

57.
McGinty EE, Goldman HH, Pescosolido BA, Barry CL. Portraying Mental Affliction and Drug Addiction as Treatable Health Conditions: Effects of a Randomized Experiment on Stigma and Discrimination.

Social Science & Medicine.
2015;126:73–85.

[PubMed]
[Google Scholar]

58.
Chambers LA, Rueda S, Baker DN, et al. Stigma, HIV and health: a qualitative synthesis.

BMC public health.
2015;15(i):848.

[PMC free article]
[PubMed]
[Google Scholar]

59.
Romer D, Bock M. Reducing the stigma of mental affliction amongst adolescents and young adults: The furnishings of handling data.

Journal of health communication.
2008;13(8):742–758.

[PubMed]
[Google Scholar]

60.
Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG. “A Disease Like Whatever Other”? A Decade of Change in Public Reactions to Schizophrenia, Depression, and Booze Dependence.

The American Periodical of Psychiatry.
2010;167:1321–1330.

[PMC free commodity]
[PubMed]
[Google Scholar]

61.
Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies—tackling the opioid-overdose epidemic.

New England Journal of Medicine.
2014;370(22):2063–2066.

[PubMed]
[Google Scholar]

63.
Marlatt GA, Larimer ME, Witkiewitz Thousand.
Damage reduction: Pragmatic strategies for managing high-risk behaviors.
Guilford Press; 2011.
[Google Scholar]

64.
Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated? A systematic literature review.

Drug and alcohol dependence.
2014;145:48–68.

[PubMed]
[Google Scholar]

65.
Abdul-Quader AS, Feelemyer J, Modi S, et al. Effectiveness of structural-level needle/syringe programs to reduce HCV and HIV infection among people who inject drugs: a systematic review.

AIDS and Behavior.
2013;17(9):2878–2892.

[PMC free article]
[PubMed]
[Google Scholar]

66.
Ritter A, Ritter A, Cameron J, Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs.

Drug and booze review.
2006;25(6):611–624.

[PubMed]
[Google Scholar]

67.
Beletsky Fifty, Davis CS, Anderson East, Burris Due south. The law (and politics) of safe injection facilities in the Usa.

American journal of public health.
2008;98(2):231–237.

[PMC free commodity]
[PubMed]
[Google Scholar]

69.
Vocaliser M, Page JB.
The social value of drug addictions: uses of the useless.
1. Walnut Creek, CA: Left Coast Printing, Inc; 2014.
[Google Scholar]

seventy.
Baglivio MT, Wolff KT, Piquero AR, Greenwald MA, Epps N. Racial/ethnic disproportionality in psychiatric diagnoses and treatment in a sample of serious juvenile offenders.

Journal of youth and adolescence.
2016:one–28.

[PubMed]
[Google Scholar]

71.
Han B, Compton WM, Jones CM, Cai R. Nonmedical prescription opioid use and utilize disorders among adults aged 18 through 64 years in the U.s., 2003–2013.

JAMA : the journal of the American Medical Association.
2015;314(14):1468–1478.

[PubMed]
[Google Scholar]

72.
Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the by 50 years.

JAMA psychiatry.
2014;71(7):821–826.

[PubMed]
[Google Scholar]

76.
Barry CL, Huskamp HA, Goldman HH. A Political History of Federal Mental Health and Addiction Insurance Parity.

Milbank Quarterly.
2010;88(3):404–433.

[PMC gratis article]
[PubMed]
[Google Scholar]

77.
Mechanic D. Seizing Opportunities Under The Affordable Care Act For Transforming The Mental And Behavioral Health System.

Health Affairs.
2012 Feb one;31(2):376–382.

[PubMed]
[Google Scholar]

eighty.
Pierson P. When effect becomes crusade: Policy feedback and political change.

World politics.
1993;45(04):595–628.

[Google Scholar]

81.
Grob GN.
The mad amid us: A history of the care of America’due south mentally sick.
Free Press; 1994.
[Google Scholar]

82.
Sharfstein S. Status of Stigma, 2012.

Psychiatric Services.
2012;63(10):953.

[PubMed]
[Google Scholar]

83.
Link B, Castille DM, Stuber J. Stigma and coercion in the context of outpatient treatment for people with mental illnesses.

Social Scientific discipline & Medicine.
2008 Aug;67(3):409–419.

[PubMed]
[Google Scholar]

84.
Torrey EF. Deinstitutionalization and the rise of violence.

CNS spectrums.
2015;twenty(03):207–214.

[PubMed]
[Google Scholar]

85.
Torrey EF. Stigma and violence: Isn’t it time to connect the dots?

Schizophrenia bulletin.
2011;37(five):892–896.

[PMC complimentary article]
[PubMed]
[Google Scholar]

86.
Torrey EF.
The Insanity Offense: How America’south Failure to Treat the Seriously Mentally Ill Endangers Its Citizens.
WW Norton & Company; 2012.
[Google Scholar]

87.
Stimson JA.
Tides of Consent: How Public Opinion Shapes American Politics.
New York: Cambridge University Printing; 2004.
[Google Scholar]

89.
Barry CL, Kennedy-Hendricks A, Gollust SE, et al. Understanding Americans’ views on opioid pain reliever abuse.

Addiction.
2016;111(1):85–93.

[PMC gratuitous article]
[PubMed]
[Google Scholar]

Why is It Important to Elevate the Stigma

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5794622/