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ature by Cornell University indicates that "none of the data give any support to the sensationalized caricature of the mentally disordered served up in the media."

Although stigma and shame are still the dominant attitudes towards mental health and mental illness, there has been a dramatic shift in perception during the last ten years. Advancements and improvements in the legal system have had a positive impact on attitudes and knowledge relating to all disabilities and to mental illness in particular. This has, in turn, created a greater openness towards all mental health issues. Additional contributing factors include public and professional awareness that prolonged hospital stays can be disabling; advances in pharmacology; and a shift in focus from pathology to strengths and abilities. More importantly, a variety of service models have been developed and implemented over the past decade which are successful in helping people with a depressive illness and other mental illnesses secure and maintain employment.¹¹

Work, unemployment, disability and promotion of mental health

A review of studies on the mental and physical health effects of unemployment and the mechanisms by which unemployment causes adverse health outcome reveals a complex relationship.¹² There has been a serious debate about the direction of causality. Does unemployment cause a deterioration in health, both mental and physical? Are the sick more likely to become unemployed?

Cross-sectional and longitudinal studies have consistently found poorer psychological health in unemployed compared with employed people, for example:

* A U.S. prospective study clearly showed that men aged 35 to 60 years who became unemployed had higher levels of depression and anxiety than those who were employed.¹³

* A review of 46 epidemiologic studies on the impact of unemployment on health, published in the Journal of public health policy (1997), showed the relationship between unemployment, employment, and job loss and a variety of mortality and morbidity outcomes. "The evidence suggested a strong, positive association between unemployment and many adverse health outcomes,"¹⁴it states.

* In a study reported in the Journal of community psychology (1994), an analysis of employed respondents not diagnosed with major depression at first interview revealed that those who became unemployed had over twice the risk of increased depressive symptoms and diagnosis of clinical depression than those who remained employed. The reverse causal path from clinical depression to becoming unemployed was not supported by the data. The unemployment rate in the respondents' community at time of interview was not related directly to psychological depression but appeared indirectly with depression via its impact on the risk of becoming unemployed.¹⁵

In its most recent investigation into work and disability in the United States, the National Institute on Disability and Rehabilitation Research (NIDRR) stated that there is a deficit in the amount of national data on the employment status of people with disabilities which includes information on psychiatric disabilities.¹⁶ The current approach towards disability emphasizes people with disabilities acting independently in their own environ-