Human Rights Violations and Mental Illness

The literature review identifies and examines human rights violations experienced by individuals with mental illness on a global level. In addition, the intent is to explore how current legislation either reinforces or supports these violations. The authors conducted an extensive review of the existing literature on mental health and human rights violations. Keywords were used to exhaust databases on this subject matter and to collect data, interpretations, and government publications on mental health and human rights. Individuals with mental illness are experiencing human rights violations on a global scale both within and outside of psychiatric institutions. These violations include denial of employment, marriage, procreation, and education; malnutrition; physical abuse; and negligence. This information was reviewed and compiled into the following article, along with interpretations of current implications and suggestions for future research. It is evident that more supports need to be instilled, especially within the context of low- and middle-income countries lacking adequate staffing and accessible services. Furthermore, legislation needs to be modified, updated, or created with relevant systems in place to make these laws enforceable.


Introduction
It is estimated that approximately 500 million individuals globally are affected by mental illness (International Labour Organisation, 2000). The World Health Organization (WHO; 2012) speculates that depression alone will rank second highest in the global burden of disease by 2020. In Canada, it is believed that mental illness will affect approximately 20% of the population in their lifetime (Regehr & Glancy, 2010). According to recent figures, the direct and indirect economic cost of mental illness is estimated to range from 48 to 50 billion dollars (Lim, Jacobs, Ohinwaa, Schopflower, & Dewa, 2008). This significant expense is not expected to decrease, but rather increase over time and moreover affect the labor force while straining the world economy (International Labour Organisation, 2000). Given the inherent vulnerability of those with mental health issues and the stigma of being a burden on society, it is essential that human rights are acknowledged for this population and also that human rights violations are globally recognized and curtailed. Reports show that individuals with mental health issues are maltreated and marginalized due to the nature of their illness. This trend is attributed to a number of factors including culture, ethnicity, religion, language, and poverty.
Although there are ongoing discourses over the treatment of individuals diagnosed with mental illness and those exhibiting mental health symptoms around the world, it is important to note that the severity of abuse varies from one culture to another based on inherent beliefs. For instance, just as in certain cultures, women are not accorded equal rights and are relegated to the background, some cultures perceive the mentally ill as not being part of normal society; therefore, those with mental illness are subjected to varying forms of abuse. The maltreatment and abuse of the mentally ill have been widely captured in literature (Awad & Voruganti, 2008).
The focus of this study was to explore the literature on how mental health issues affect the rights of individuals with mental illness. The rationale for this literature review is to examine globally the human rights abuses of mental health issues and shed light on its impact on economies worldwide. Furthermore, this review intends to explore options to enhance the treatment adherence to practices that will improve the conditions of individuals marginalized due to their mental health condition.
Simply put, the question to be explored will be to "examine how human right abuses/violations affect the mentally ill globally." The study will review the literature as a foundation to our findings and then give recommendations.

Literature Review
Mental health embodies the integration of psychological, emotional, and social harmony. It encompasses ones quality of life and general well-being. Culture, language, ethnicity, and religion play a significant role in the interpretation of mental health causes. Studies show that being diagnosed with or exhibiting symptoms of mental health issues exposes a person or community to labeling. Such people are branded as socially inadequate and are associated with resulting shame, humiliation, and loss of face. In most cultures, groups with low positions in hierarchical social structure experience high rates of mental health problems (Rosenfield, 2012). In modern society, connection with mental illness exposes a person to levels of medicalization and marginalization.
In certain cultures, mental illness is perceived as a sign of weakness or curse. This negative connotation results in family members distancing themselves from or maltreating those who are ill. Furthermore, those with mental illness are deemed unproductive and perceived as not contributing to the upkeep of the family. It is also argued that the lack of resources in African countries as well as in other developing countries makes it difficult for governments to enhance the treatment or improve the conditions of the mentally ill, which inevitably exposes many to abuses.
Over the years, research has shown that stigma plays a significantly debilitating role in the treatment of the mentally ill (Barke, Nyarko, & Klecha, 2011;Link et al., 2001). The literature on stigma describes how individuals with disabilities, including mental illness, often find themselves on the periphery of society. This circumstance is deemed "an attribute that is deeply discrediting" (Goffman, 1963, p. 3). Such individuals are marginalized, mistreated, and often stigmatized in society. Individuals with mental illness are often viewed as "strangers" where this characteristic of "strangeness" frequently results in social distancing (Baumann, 2007). Unfortunately, as this treatment is prevalent in both the industrial and developing countries, the argument could be made that governments are failing to put in place measures or systems to enhance the treatment of the mentally ill. Thus, very limited progress has been made to improve the lot of the mentally ill who are ostracized in society.

Method
The intent of the study was to review the global literature on the subject and examine how different cultures respond to this topic. The search criteria included papers on the treatment of the mentally ill in various countries throughout the world. The major databases used to identify the articles were PubMed, PubMed Central Canada, SAGE Journals, African Journals Online, Scholars Portal, EBSCOHost, ProQuest, PsycINFO, and Google Scholar. The WHO database was also examined for the purpose of this venture. Only papers published in English were allowed for consideration in this review. The review examined peer-reviewed published articles, policy papers, as well as government publications since 2000. Keywords or statements of combinations of these terms were included in the search along with librarian assistance. Keywords (and a combination of these words) included mental health*, mental illness*, rights, human rights*, psychiatry*, human rights violations and mental illness, colonial psychiatry, and deprivation of liberty. This method yielded numerous articles related to mental illness and human rights.
In the process of searching the literature, keywords (rather than titles and abstracts) were used to examine the documents for matches. All of the references were recorded and stored electronically using refworks. Tracking was conducted after reading the papers and bibliographies were reviewed for further documents. The criteria for inclusion included both qualitative and quantitative articles on human rights and mental illness. For the purpose of this study, literature reviews and meta-analyses were not included. In the event that the same data were reported by two different papers, only the first report has been included. Papers published in peer-reviewed journals and gray literature were included.
Given this study's objective on mental health and human rights violations, certain articles were excluded from review, in cases where it was determined that the study, article topic, or demographic lay outside of the purview of this article. Information was recorded down in the form of notes, entered into a literature table (see Appendix), and categorized by themes which are represented in the following "Results" section.
In total, approximately 1,000 articles, book chapters, and dissertations were found. Of these, 200 papers were reviewed because they either focused or had some discussions on mental health and human rights abuses. Articles were excluded for numerous reasons including the following: reported the same data as other papers, did not explore issues being looked at, literature reviews and meta-analysis. Nevertheless, the most significant were those that focused on mental health and human rights or articles that reflected research conducted internationally. Of the resulting articles, book chapters, and theses elicited from the search, 37 articles were deemed appropriate and utilized for the purpose of adequately addressing human rights and mental illness. Thus, from the 200 papers reviewed, a preliminary review narrowed the findings to 37 articles and government publications--31 articles and 6 government documents. Articles that did not specifically focus on human rights and mental illness were excluded. Theses and book chapters that did not directly address the issues of human rights and mental illness were excluded as well.

Illiteracy and Mental Health
The findings emphasized the importance of taking note of the co-morbidity of illiteracy and mental illness. This has been linked to an increased likelihood of experiencing human rights violations, as illiteracy can adversely affect the ability to reach out for formal supports. In India, illiteracy has a greater influence on women than men, where despite free education, women are less likely to be encouraged to attend school (Vijayalakshmi, Ramachandra, Reddemma, & Math, 2012).
Stigmatization may also play a role in the educational opportunities for those with mental health issues as reflected by the high incidence of dropouts. Students with mental illness can face teasing, harassment, and prejudice from their peers, and arguably, their teachers (WHO, 2010).

Development Programs and Mental Health
Despite the creation of development programs intended to improve the lives of the world's most vulnerable populations, such programs exclude, often intentionally, the mentally ill as part of their recipients. A striking example is the Bangladesh Vulnerable Group Development Program, which stipulates that service users needed to be "mentally and physically sound" to access the program (WHO, 2010, p. 3). UN Secretary-General Ban Ki-moon clarifies the implications of this exclusion: The rate of mental disorders and the need for care is highest among disadvantaged people--yet these are precisely the groups with the lowest access to appropriate services. At the same time, fear of stigma leads many to avoid seeking care. The consequences are enormous in terms of disability, human suffering and economic loss. We have a pressing obligation to scale up care and services for mental disorders, especially among the disadvantaged, while stepping up efforts to protect the human rights of those affected. (WHO, 2010, p. 7) This inequality even extends to emergency and disaster situations. After Hurricane Katrina in the United States, Federal Emergency Management Agency (FEMA) allegedly discriminated against those with mental health issues based on the belief that these individuals were dangerous (WHO, 2010).
Furthermore, the unemployment rate for mentally ill individuals is approximately 70% to 90%; yet, development programs that create job opportunities often omit these individuals in their planning and enactment of projects (WHO, 2010).

Prison Settings and Mental Health Court
In fact, individuals with mental illness who are receiving care in psychiatric institutions suffer greater human rights violations than individuals who are in correctional facilities. While those in psychiatric care may not have committed a crime, they are subjected to a similar removal of rights and liberties as with a criminal offender. Comparable with their criminal counterparts, individuals with mental illness are perceived as "more dangerous [and] less competent"; two qualities that are not welcome within general society (Diseth & Hoglend, 2011, p. 393).
An additional area of concern regards individuals determined to be not criminally responsible and therefore detained either in the psychiatric section within a prison or in a designated wing within a hospital setting. According to Fellner (2006), the majority of incarcerated individuals in the United States of America are struggling with mental health issues: Indeed, one of the primary roles of prisons in the United States today is to house the mentally ill. Prisoners have rates of mental illness that are two to four times greater than the rates of members of the general public. (p. 1) Housing of the mentally ill in prisons can be partially attributed to the lack of community-based services that were to be developed as a result of hospital closures (Fellner, 2006).
Regardless of the environment, the intent is to provide psychiatric treatment to accommodate the unique needs of the prison population. However, issues arise, such as the cohabitation of varying degrees of mental health severities, lack of appropriate professional training for staff members (Naudts et al., 2005), disciplining individuals instead of providing psychiatric support, verbal abuse and neglect from staff, and the exacerbation of mental illness due to confinement (Fellner, 2006). As symptoms of mental illness may be viewed by untrained prison staff as behavioral issues, these prisoners can build lengthy disciplinary records, which could potentially negatively affect their release time (Fellner, 2006;Matejkowski, Caplan, & Cullen, 2010). Reintegration into society and the opportunity for parole are often contingent upon program participation; yet, these classes infrequently consider the additional support that individuals with mental illness may require. In addition, programs may not address certain life skills that are unique to those with mental illness such as compliance with medication (Matejkowski et al., 2010).
Szasz (as cited in Breeding, 2006) suggests that those with mental illness who have been involuntarily admitted may be treated worse than their criminal counterparts: A prisoner will be released after he completes his sentence, and possibly before. A mental patient may be required to undergo a change in his "inner personality"-a change that may be induced by measures far more intrusive than anything permitted in a jail-before the psychiatric authorities let him go. And they may never let him go. Commitment, unlike a sentence, is for an indefinite period. (p. 252) Breeding (2006) further highlights the contradiction of justice: Individuals in mental health court are guilty until proven innocent. The added danger is that an individual's refutation of a diagnosis can be interpreted as a symptom of their mental illness.

Physical Health and Mental Health
The gap in service provision for those with mental illness transfers into the health care system as well. Those with mental illness are at a higher risk of acquiring considerable physical health problems, which potentially shortens their lifespan (WHO, 2010). Human rights violations occur frequently within health care settings, if these services are available to those with mental health issues at all (P. Hunt & Mesquita, 2006). An example of this neglect can be found in a shelter in Indonesia that houses individuals with mental illness. During a 7-month time period, 181 of the 644 individuals died of diarrhea or lack of nourishment (WHO, 2010). Tarantola (2007) points out a cyclical relationship between physical and mental health. Those who experience human rights violations are at an increased risk of experiencing physical health concerns. Poor health, in turn, increases individuals' susceptibility to human rights violations (Tarantola, 2007). Callaghan and Ryan (2012) review the practices of compulsory treatment in Australia and stated that this form of treatment should only concern individuals who are unable to make independent decisions. While this could equally result in a human rights violation, the authors suggest the following criteria for an individual who is able to make decisions: ability to comprehend, recall, repeat, and utilize the information presented to them (Boyle, 2011;Callaghan & Ryan, 2012). In 2004, the European Court of Human Rights emphasized that temporarily detaining an individual who does not offer consent, nor has the capacity to do so, could be considered a deprivation of liberty. In response, the Deprivation of Liberty Safeguards was implemented to ensure the rights of individuals in this position (Boyle, 2011).

Social/Cultural Stigmatization of Mental Illness
While medical conditions typically have tests, lists of symptoms, and clear treatment methods, mental illness are not as "tangible" and can therefore be viewed as less credible, which only furthers stigmatization (Loo, Trollor, Alonzo, Rendina, & Kavess, 2010, p. 423). This lack of understanding of mental illness conducted through a biomedical lens rather than from the perspective of "social justice, quality of life, human rights and human security" (Giacaman et al., 2011, p. 547). This also raises the concern of applying Western standards and mental health techniques in countries where there are alternative understanding of mental illness, descriptive language, and treatment techniques. Some countries continue to rely on traditional and/or faith healers, family, and community to remedy their mental health issues (Giacaman et al., 2011;Vijayalakshmi et al., 2013). Davar (2008) suggests that the West's insistence that medication is more effective than counseling in low-income countries may be influenced by underlying tones of colonialism or even as a means to create further profit for the pharmaceutical industry.
Further to not knowing their rights, individuals with mental health concerns are often stigmatized by societal and cultural views. From "not . . . a human being at all" to being seen as "facing punishment for their past actions," individuals struggle to find support within their community, not to mention on a higher systemic level (Drew et al., 2011(Drew et al., , p. 1669. The occurrence of stigmatization is exacerbated with the viewpoint that the cause of mental illness is internal and not something that can be addressed from a social or systemic shift (Kogstad, 2009). In India, the principle of karma can impede those with mental illness from reaching out for support due to its implied culpability (Vijayalakshmi et al., 2013). Society also stereotypes those with mental illness as feeble, aggressive, of lower intelligence, or even victim to paranormal influences (WHO, 2010).
As evident throughout this review, it is important to consider culture when studying the types of treatments offered in different communities. For example, out of the 25 nations reviewed by the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS), Korea ranked third in terms of involuntary admissions to hospital. This has created concern regarding forcible admission; however, it is suggested that these numbers must be viewed through a cultural lens. Bola, Park, and Kim (2011) indicate that these numbers can be attributed to the fact that stigma prevents individuals from voluntarily accessing treatment; also, these services may not be adequately supported financially for individuals.

Addressing Stigma
Given the scope of individuals who are affected and how this relates to national levels of success and accountability, implementing education and awareness programs is essential to decreasing stigmatization (Mwanza et al., 2011). However, it should also be noted that stigmatization is a primary cause of human rights violations and that labeling individuals can in fact cause further harm to this population. This gap seems to have been addressed on a grassroots level by nongovernmental organizations (NGOs) and community efforts through support groups and implementation of traditional healing practices (Dhanda & Narayan, 2007).
The concept of spreading awareness is imperative to normalizing a stigmatized population, as lack of infrastructure and monitoring in psychiatric institutions leaves the public unaware of the aforementioned human rights violations (P. Hunt & Mesquita, 2006). However, the notion of education surrounding mental health standards faces a financial barrier, as this agenda is much more accessible to countries that are recognized as high income. Through their research, Drew et al. (2011) identify that the majority of low-income and middle-income countries were not adequately equipped to support those needing to access mental health services.

Violations
Violations of individuals diagnosed with mental health disorders vary from one culture/country to another. These violations may be dependent on the cultures of the country in question or the resources available to those countries. For instance, more resources are allotted to the treatment of mental illness in high-income countries than in low-income countries. In high-income countries, it is ensured that trained professionals are available to treat individuals diagnosed with mental illness. To be specific, the income level of the world based on its Gross Domestic Product (GDP) is divided in categories. According to the World Bank, economies are measured by their gross national income (GNI). According to the 2011 GNI, a lower income country was considered USD $1,025 or less; a lower middle-income country was $1,026 to $4,035; an upper middle-income country was $4,036 to $12,475; and a highincome country was $12,476 or more (World Bank Data, 2013). High-income countries are often developed countries; middle-income countries as well as some developing countries contain emerging markets; and lowincome countries mostly consist of developing countries.
The violation and stigmatization of individuals diagnosed with mental illness include discrimination surrounding employment, marriage, parenting, and family planning; access to health services; sexual violence; access to housing; entitlement to vote; and access to basic education (Drew et al., 2011;Vijayalakshmi et al., 2013;WHO, 2010). While it may be presumed that these violations are specific to underdeveloped countries, the inability to marry exists in Bulgaria, Russia, Thailand, and India. In Switzerland, though known for its neutrality, applications of nationality can be declined if an individual struggles with intellectual disabilities. In addition, only Canada, Ireland, Italy, and Sweden (out of 63 countries assessed) do not place legal limitations on voting for individuals with mental illness (WHO, 2010).
The violation of the mentally ill has been reported as occurring in a variety of settings ranging from home life to schools, prisons, work environments, and social services (Drew et al., 2011). The traits of the mental health care system are regularly identified as inadequate and emotionally or physically abusive (Cooper, Ssebunnya, Kigozi, Lund, & Flisher, 2010). Individuals are often institutionalized for long periods of time without appropriate cause and are then subjected to conditions that include violence, substandard nutrition and cleanliness, torment, unconsented treatment as extensive as electroconvulsive therapy (ECT; P. Hunt & Mesquita, 2006), loss of dignity (Kogstad, 2009), and sedation as a control method (Mayers, Keet, Winkler, & Flisher, 2010). Violations in Zambia have included denial of food, restriction of movement, poverty due to cost of treatment, and being brought to hospital in chains or in the company of armed officials (Mwanza et al., 2011). Treatment can also fail to involve basic social communication, as some believe that this would not be helpful to an individual with mental health concerns (Kogstad, 2009).
While the Cochrane Review highlights the lack of empirical evidence for the effectiveness of isolation and use of restraint, these practices, along with sedation, are frequently implemented within institutions. The review also references that within the literature, certain qualitative studies have in fact pointed to negative outcomes. Another concern that is equal to the use of possibly nonbeneficial practices is the intent behind the use, as sedation can be implemented for purposes of control rather than as a means of support for the individual (Mayers et al., 2010).
Further violations can be witnessed in a number of different countries. As described by Yamin and Rosenthal (2005), in Accra, Ghana, 300 mentally ill men were housed in a space that was built for 50 individuals and were not provided with treatment. In Hungary, individuals were administered obsolete medication and kept in beds that were caged, thereby limiting their movement. In Turkey, Peru, and Bulgaria, institutions engage in the dangerous practice of unmodified ECT, which does not utilize anesthesia.
Certain countries perpetuate human rights violations due to the lack of appropriate and accessible staffing. Less than 50% of hospitals in Bangalore, India, have psychologists available to their patients. Some of these violations occur due to a long-standing history of cultural or faith-based practice regarding treatment of the mentally ill (WHO, 2010). For example, in Somalia, an individual may be placed in a hollow with hyenas. The intent is to scare the "dijinns, or evil spirits" from the person, and therefore the symptoms of mental illness (WHO, 2010, p. 12). Other faith-based or traditional practices can involve restriction of movement through chains or attempts to remove spirits by whipping the mentally ill person (Doku et al., 2011).
These violations extend to accessing of justice, civil, and political rights. In England and Wales, a report by Mind discovered that 60% of individuals with mental illness who approached police regarding a crime felt that the authorities did not treat the report with severity. In certain instances, reports are not documented due to the belief that individuals with mental illness are unreliable (WHO, 2010).
Within the population of individuals with mental disorders, there are subgroups who are at an increased risk of violation. For example, those of varying ethnicities and race are more likely to experience prejudice and women are more likely to be sexually abused and even sterilized without consent (P. Hunt & Mesquita, 2006). Kastrup (2011) notes the disparity between mental health support for those within marginalized populations, as well as the lack of human rights fulfillment.
In 1993, the slogan "Human Rights Are Women's Rights" became a prominent message. During the World Conference on Human Rights in Vienna (Jansen, 2006), it was agreed that violence against women was considered a human rights issue. This practice is most notably seen during times of war, when sexual violence against women can increase and be used as a tool of war. This violence can lead to fear or mental health issues that deter women from being active community members, which further exacerbates the issue of human rights (Jansen, 2006). Violations can also be seen within the very institutions that are meant to support women with mental health issues, such as in Kosovo, where incidents were reported in which women were raped in psychiatric institutions while the violence was witnessed by staff and humanitarian workers (Yamin & Rosenthal, 2005).

Legislation
Despite the issues of mental health violations documented in the literature, it has also been observed that significant legislations are documented pertaining to the treatment of individuals with disability including those with mental disorders. The Universal Declaration of Human Rights (UDHR) encompasses 30 articles; however, no articles identify the need for rights around mental health concerns, and only one article (Article 25) alludes to the importance of social service access (The United Nations, n.d.). Instead, information about mental health can be found in the United Nations Convention on the Rights of Persons with Disabilities. As defined here, disabilities include "long term . . . mental . . . impairments . . . which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others" (The United Nations, 2006, Article 1).
To ensure that human rights are honored in relation to mental health, WHO developed the Mental Health and Human Rights Project, which focuses on mental health legislation within a global context (WHO, 2006). This project was supplementary to the United Nations Principles for the Protection of Persons With Mental Illness and the Improvement of Mental Health Care, which was established in 1991 and created a minimum level of human rights required in mental health practice (WHO, 2005). However, the principles (known as the Mental Illness [MI] Principles) have been critiqued as being ineffective and contrary to the UDHR. It is noted that the MI Principles are not legally binding and fail to institute any form of international supervision (Weissbecker, 2009). The UN Secretary-General stated that they "offer in some cases a lesser degree of protection than that offered by existing human rights treaties, for example, with regard to the requirement for prior informed consent to treatment" (WHO, 2005, p. 14). P. Hunt and Mesquita (2006) indicate that "several international human rights instruments allow for exceptional circumstances in which persons with psychiatric disabilities can be involuntarily admitted to a hospital or other designated institution" (p. 344). However, such vague terms protect the regular occurrence of human rights violations (Kogstad, 2009). The case of Harry v. Mental Health Review Board in Australia illustrates an example of improper use of mental health law to alleviate embarrassment from family or communities (Freckelton & McGregor, 2010).
These statements call into question the voice of the service user and whether human rights in regard to mental health are indeed being honored. This concern is exacerbated by the fact that individual countries are able to enact their own regulations, definitions of mental health disorders, and principles. As a result, more than 40% of countries lack a mental health policy and more than 30% of countries lack a mental health program (P. Hunt & Mesquita, 2006). In some countries such as Zambia, policies exist but are antiquated, offensive, and based on colonial eras (Mwanza et al., 2011). The lack of legislation can also be attributed to the use of traditional and faith-based practices, which often go unregulated (Doku et al., 2011).
In addition, legislation may be put in place to manipulate social participation. According to WHO (2005), "In many countries a diagnosis of personality disorder has been used against vulnerable groups, especially young women, whenever they do not conform with the dominant social, cultural, moral and religious standards" (p. 21). This method of mental health diagnoses is also used for political purposes to attribute personality disorders to those who may be viewed as a nonconformist (WHO, 2005). In addition, in India, women viewed as oppositional can be branded as insane (Davar, 2008). To create uniformity among the concept of mental health, Tarantola (2007) suggests a more holistic understanding, which would include emotional, social, and cultural influence and welfare.
While the intention of establishing universal guidelines such as UDHR, UNCRPD (UN Convention on the Rights of Persons with Disabilities), and MI Principles is important for those within the government and legislative context, this does little to provide information to those who are directly affected. A survey participant from Jordan stated that "the most important right is my right to have the knowledge of all of my rights and to be empowered to [confront] violations against my rights" (Drew et al., 2011(Drew et al., , p. 1666. This right to knowledge relies heavily, however, on the assumption that the legislation in fact supports those with mental health issues. Uganda's mental health system is an example of a legislation that is in accordance with international policy; yet, it is criticized for its perpetuation of stigmatization and violation of human rights for those with mental health concerns (Cooper et al., 2010). These guidelines additionally rely heavily on agreement, commitment, compliance, and mutual understanding of the issues of mental health and human rights.

Discussion
Human rights violations not only affect the physical, psychological, emotional, and spiritual well-being of service and nonservice recipients with mental disorders but also significantly influence potential service recipients' access to mental health services, thereby creating a dynamic where not receiving any form of treatment or support may become more desirable (Loo et al., 2010).
Furthermore, culture, religion, and traditional practices play a role regarding which type of mental health treatment is sought out by individuals. Some individuals do not believe that mental illness exists or that only the physical symptoms need to be addressed (McDaid, Knapp, & Raja, 2008). This view can be partially attributed to lack of professional and public knowledge, resulting in the stigmatization of this population.
Absence of resources may be symptomatic of an overlying cause of lower socioeconomic status. While dedication to mental health and humane treatment of these individuals is a noble cause, this may not be feasible in certain countries. Ethiopia is home to 77 million people but only 18 psychiatrists, who are all employed in one hospital, located in the capital city (Alem, Jacobson, & Hanlon, 2008). Even if legislation were put into place, what would be enforced in the rural areas where individuals are not receiving formal care? Bruckner et al. (2011) estimate that 239,000 full-time employees would be required in low-and middle-income countries just to have adequate staffing. A proposed solution is to increase staff presence and emphasize community-based care, which would increase access and honor the human rights of individuals. According to Yamin and Rosenthal (2005), From a human rights perspective, people are entitled to live in and receive care in the community not because it is more efficient, but because all human beings develop their identities within social contexts, and have rights to work and study, as well as be with friends and family. (p. 297) Research into why human rights violations occur may be beneficial in creating a comprehensive plan to better ensure human rights of those with mental health issues. A psychiatrist in Ghana presents the following dilemma: . . . people are trying to do their best to help people with mental illness, but when there is inadequacy and all those things set in, we don't intentionally try to violate people's rights. But when you keep someone in the mental hospital and you can't provide for the person, you then of course, you are violating that person's rights. (Doku et al., 2011, p. 18) Furthermore, it is evident that legislation needs to be created which honors human rights, as there is a clear disparity between experiences of those with mental health concerns and the intent of human rights (Kogstad, 2009). However, it is also clear that these movements be considered within the contextual framework of culture and religion. P. Hunt and Mesquita (2006) suggest that legislation should consider the following when making decisions surrounding human rights and mental health: "participation, autonomy, dignity, inclusion, monitoring, and accountability" (p. 332). In response to this need for individual voice, the International Diploma on Mental Health Law was conceived, it comprised of an interdisciplinary team including service users and aiming to provide education, awareness, and reform on a countrywide basis (Drew et al., 2011). The Mental Health and Poverty Project (MHaPP) is an initiative focusing on the cyclical nature of poverty and mental health in Ghana, Zambia, South Africa, and Uganda (Mwanza et al., 2011). While more integrated, this initiative solely focuses on African countries, which possibly negates the presence of human rights violations in more "developed" countries and creates further stigmatization for a continent that is already branded by poor global opinion.
Clearly, the prevalent issue of human rights violations in the context of mental health can no longer be ignored. However, given the additional factors and barriers of income status, accessibility, culture, religion, and traditional practices, it will be a challenge to create an understanding and enforcement of universal human rights. To completely dismiss cultural tradition would only contradict another set of human rights, thereby exchanging one form of violation for another. Thus, discussion is necessary regarding how one can balance the rights of traditional or faith-based practice with the UN's view of human rights.
This therefore creates the need for both advocates and researchers to continue challenging and embarking on studies that will improve the lot of the mentally ill. For progress to enhance mental health treatment in numerous countries, serious intervention and engagement from governmental bodies are necessary.
Despite these arguments, one should not lose sight of the fact that programs have been introduced in the Western world to improve the treatment of the mentally ill. For example, the work of Winick and others on therapeutic jurisprudence has been designed to shift the treatment of the mentally ill from the medical model to a more collaborative approach. This shift in direction commenced in the 1980s as an interdisciplinary scholarly approach to enhance the treatment of the mentally ill (Winick, 2002(Winick, , 2006. Since then, a number of interventions have been introduced in the treatment of the seriously mentally ill in the Western world, including Community Treatment Orders (CTOs) or Mandated Outpatient Treatment which legally compels individuals diagnosed with mental illness to follow through with a proposed treatment or else risk being hospitalized (A. M. Hunt, da Silva, Lurie, & Goldbloom, 2007;Kisely, Campbell, Scott, Preston, & Xiao, 2007;Mfoafo-M'Carthy & Williams, 2010).
In addition, it should be noted that the study adds to the literature on issues of human rights abuses of the mentally ill and contributes to the discourse. Also, it continues to bring attention to the stigmatization of the mentally ill and the need for more education and understanding of the needs of this marginalized community.

Limitation
This review may not be considered exhaustive due to the fact that the literature reviewed were only English language articles, this eliminates the cross-cultural perception of the study as articles in other languages were excluded. Also, all the articles reviewed focused solely on Westernized perception or definition of mental illness, which does not enhance the diversity of the discourse.

Conclusion
Based on the findings of this review, the literature clearly articulates the importance of creating a system that will curtail the marginalization and stigmatization of individuals diagnosed with mental disorders. The review identified legislations intended to limit the human rights violations of individuals with mental health issues, yet not much has been achieved. Even in the Western world, programs including the work of Winick on therapeutic jurisprudence and other treatment options such as CTOs aimed at enhancing treatment to limit mental health violations have not made a significant impact. A major factor to improving the conditions of the marginalized is to curb violations against the mentally ill through meaningful engagement and political will on the part of governments. The observation is that, despite laws governing the treatment of those with mental health issues, much has not been done to address stigmatization of individuals diagnosed with serious mental illness. In developing countries and other parts of the world, family members with mental health issues continue to be marginalized, medicalized, and ostracized, hence exposing them to human right abuses. • It also proposes to replace this test with a "best interests" test (p. 1)

Summary
• Evidence suggests that assessing for future harm is ineffective and a potential detriment to individuals with mental illness.
• Article suggests that "best interests" test would be more appropriate in deciding the treatment protocol for clients.
• Article defines what it means for a client to be unable to make a decision regarding their own mental health care Cooper, Ssebunnya, Kigozi, Lund, and Flisher (2010) Viewing Uganda's Mental Health System Through a Human Rights Lens Reviewed first stage of MHaPP as completed in Uganda; quantitative data were gathered through WHO-AIMS; qualitative data were gathered through interviews and focus groups • "Despite possessing a draft mental health policy that is in line with many international human rights standards, Uganda's mental health system inadequately promotes and protects, and frequently violates the human rights of people with mental disorders" (p. 578) • Human rights violations include physical and emotional abuse, inadequate care. • Ugandan legislation uses offensive language in describing mentally ill individuals (e.g., "lunatics," of "unsound minds," p. 580) Davar (2008) From Mental Illness to Disability: Choices for Women Users/Survivors of Psychiatry in Self and Identity Constructions Journal article • Reviews the women's movement in mental health in India • Women who are seen as rebellious can be diagnosed with a mental illness. • Certain individuals argue that the use of psychiatric medication is more effectual in low-income countries than counseling. Author argues that this may be due to the colonialism and the profit attained by the pharmaceutical industry Dhanda and Narayan (2007) Mental Health and Human Rights Comment (journal article) • Suggests that human rights violations of those with mental illness is primarily due to stigmatization and labeling Western models see mental illness as internal, while oPt is collective and has experienced trauma, oppression, and injustice as a society; traditional and cultural healing practices are not considered within Western counseling; within oPt, Western medication and counseling did not appear to be effective in the community.
• Palestinian researchers indicate that local language depicts a holistic state of health and uses language that is not diagnostic but emphasizes a collective experience.
• Suggested approach: "social justice, quality of life, human rights, human security" (p. 556) P. Hunt and Mesquita (2006) Mental • There are no studies that assess the positive qualities of seclusion or restraint when used with individuals with serious mental illness. However, research exists on its harmful outcomes.
• Focus group identified the following themes: "inadequate communication, a violation of rights, and the experience of distress" (p. 66).
• Focus group provided the following recommendations: "prevent human rights abuse," "minimize isolation and distress," "privacy should be ensured," "improve communication between service providers and service users," (p. 69) "promote attitudinal changes which reflect respect for the other person's dignity" (p. 70) McDaid, Knapp, and Raja (2008) Barriers in the mind: Promoting an economic case for mental health law in low-and middle-income countries

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research and/or authorship of this article.