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Introduction
The legislation of most countries establishes the principles of protecting the rights of people with mental disorders as a socially unprotected contingent [1]. An open information space helps to develop legal literacy and awareness of mental health care recipients, which increases the quality of medical care and respect for their rights [2]. Therefore, changes in psychiatric services should be comprehensive [3]. The stigma of the “mentally ill” in the public mind leads to discrimination against psychiatric patients [4], reducing their social status and quality of life [5].
Mental health workers treat the rights and problems of their patients with disdain [6]. In a psychiatric hospital, the rights of patients are often violated: They are forced to be hospitalized, they are denied access to medical documents, they are monitored around the clock, they control their medication, and they are prevented from refusing treatment [7]. Involuntary hospitalization becomes an obstacle to compromise between the timeliness of medical care, public safety, and the patient’s right to liberty [8]. Restrictions on freedom of movement, physical restraints, and forced prescription of drugs used in psychiatric hospitals are perceived negatively by patients [9] and abused by medical staff [10].
The absence of laws on the powers of medical personnel to restrict the rights of patients, and the low level of legal literacy and knowledge in the field of bioethics of psychiatrists, paramedical personnel, and paramedical personnel lead to discrimination against psychiatric patients [11]. Coercion reduces the level of compliance of patients [12] and contributes to an increase in the frequency and severity of exacerbations of mental disorders [13].
Therefore, we assessed the opinions of people with mental disorders and psychiatrists about violence and coercion in a psychiatric hospital in order to prepare recommendations for their prevention.

Materials and Methods
The research was conducted in psychiatric hospitals in three regions of the Russian Federation-Belgorod, Volgograd, and Voronezh regions, in 2019. The objects of the study were divided into two groups: Psychiatric patients and psychiatrists.
Inclusion criteria for patients: The age of 18 years or older, diagnosis of F0 organic mental disorder, F2 schizophrenia, or F3 mood disorder established in accordance with the ICD-10 criteria, treatment in the acute psychiatric department of a psychiatric hospital, the state of becoming a therapeutic remission or persistent improvement in mental state. The exclusion criteria were the age of less than 18 years, acute psychopathological symptoms, and severe cognitive and emotional-volitional deficit.
The inclusion criterion for the group of psychiatrists was work experience in an inpatient psychiatric department for at least one year and their exclusion criterion was work experience in an inpatient psychiatric unit for less than 12 months.
An anonymous survey of 107 psychiatrists and 271 patients was conducted using a medical-sociological and psychometric method using the author’s questionnaires. The questionnaire for psychiatrists contained the following blocks: Socio-demographic information, opinions about coercion and violence in a psychiatric hospital, and assessment of one’s own social distance from people with mental disorders. The questionnaire for patients contained the following blocks: Socio-demographic data, opinions about coercion and restrictive measures in a psychiatric hospital, and criticism of the disease.
Bogardus social distance scale [14] measures social distance as the degree of closeness or alienation between people with mental disorders and respondents. The average score was used to determine the social distance of the respondents in their attitude toward psychiatric patients. Five variants of social distance were distinguished: Close relations (points 1-2), open relations (points 3-4), distancing (point 5), isolation (point 6), and rejection (point 7).
The database was processed using nonparametric statistic methods (descriptive statistics, chi-square with Yates correction for 2x2 contingency tables, and odds ratio) using the Statistica software, version 8.

Results
The group of patients included 271 people: 110 men aged 42.3±11.5 years and 161 women aged 41.8±13.4 years. Among the patients, those with schizophrenic spectrum disorders predominated (78.2%), followed by those with affective disorders (11.4%), and those with оrganic, including symptomatic, and mental disorders (10.4%).
The group of psychiatrists included 107 people: 42 men aged 37.8±13.7 years and 65 women aged 34.2±11.2 years. Work experience in the “psychiatry” specialty was 10.6±10.7 years. Also, 40.1% of psychiatrists had the highest and first qualification category.
In the group of patients, 50.6% had persistent severe mental disorders and were disabled. Among the remaining psychiatric patients, more than half (61.2%) did not work.
In addition, 23.6% of patients completely denied the existence of a mental disorder and 49.5% of patients noted various psychological problems. A mild mental disorder was recognized in 16.6% of both sexes. Full-fledged criticism of their mental disorder was noted only in 10.3% of patients.
Also, 49.5% of psychiatrists considered themselves completely healthy and 44% of psychiatrists had psychological problems, while in 5% of the respondents, these problems led to a violation of social functioning. In addition, 6.5% of physicians indicated that they were being treated by a psychiatrist or psychotherapist.
Also, 35.8% of patients and 45.8% of psychiatrists consider it justified to force psychiatrists to treat people with mental disorders in any situation, the same number of respondents -30.6% and 40.2%, respectively - in cases of auto- and hetero-aggression (Table 1).


In addition, 91.6% of psychiatrists and 72.3% of patients had a positive attitude toward the use of coercion in a psychiatric hospital (χ2=15.376, p=0.000, OR=4.1, and 95% CI, 1.9%-9.3%) and 7.4% of patients and 5.6% of psychiatrists spoke about the inadmissibility of the use of coercion and violence by psychiatrists under any circumstances. Coercion by nurses in all cases was considered justified by 23.6% of patients and 24.3% of psychiatrists. A similar number of respondents in both groups considered it possible to coerce into treatment only in the case of the patient’s aggression (28.4% of patients and 29% of psychiatrists). Also, 26.2% of psychiatrists and 12.2% of patients did not allow the use of coercion and violence by nurses in the treatment (χ2=10.087, p=0.002, OR=2.6, and 95% CI, 1.4%-4.7%).
Regarding the opinion on the use of physical restraints during voluntary hospitalization by a psychiatrist personally with agitation in a patient (Table 2), 90.7% of psychiatrists and 74.9% of patients reported allowing their use (χ2=10.6732, p=0.0019, OR=3.2, and 95%CI, 1.5%-7.0%).


The implementation of physical constraint was considered the prerogative of orderlies by 64.5% of psychiatrists (χ2=25.173, p=0.0005, OR=3.3, and 95% CI, 3.2%-5.4%) and 35.4% of patients. If a patient develops agitation, according to 28.4% of patients and 19.6% of psychiatrists, the psychiatrist can apply a physical constraint on his/her own. Also, 11.1% of patients and 6.5% of psychiatrists delegated the physical restraint of people with mental disorders to nurses.
The use of injections of sedative drugs by a psychiatrist personally in the event of a patient developing psychomotor agitation was considered justified by 81.3% of psychiatrists and 64.6% of patients (χ2=9.3268, p=0.0032, OR=2.3, and 95% CI, 1.3%-4.2%) (Table 3).


Also, 66.4% of patients and 46.7% of psychiatrists allowed the involvement of other patients to help administer sedatives (χ2=11.674, p=0.001, OR=2.3, and 95% CI, 1.4%-3.7%). In addition, 23.3% of psychiatrists approved the involvement of other patients in holding an aggressive patient in exceptional cases.
Among the respondents, 71.9% of patients and 72.9% of psychiatrists approved of the presence of special restraint belts for the application of physical restraint. Also, 59.8% of patients and 50.5% of psychiatrists spoke about the expediency of having “straitjackets” in psychiatric hospitals.
In addition, 76.4% of patients and 82.2% of physicians (Table 4) expressed that psychiatrists could personally participate in the application of physical restraint in case of agitation, which threatens the lives of others and the absence of nursing staff nearby.


The inadmissibility of the participation of a psychiatrist in the implementation of measures of physical restraint was indicated by 23.6% of patients and 17.8% of psychiatrists. The use of physical constraint by nurses on their own initiative, without the appointment of a psychiatrist, was considered acceptable by the majority of respondents in the case of psychomotor agitation in a patient with heteroaggression. Also, 88.8% of psychiatrists and 78.2% of patients admitted the participation of nurses in the application of physical restraint (χ2=4.933, p=0.027, OR=2.2, and 95% CI, 1.1%-4.5%).
The need for compulsory treatment of psychiatric patients (Table 5) “for the benefit of society” was admitted by 29.9% of patients and 10.3% of psychiatrists (χ2=14.971 p=0.0007 OR=3.7, and 95% CI, 1.8%-7.8%).


The need for involuntary treatment of patients with severe mental disorders “in their own favor” was noted by 24.4% of patients and 16.8% of psychiatrists. Public danger as the only reason for compulsory treatment was indicated by 67.3% of psychiatrists and 31.7% of patients (χ2=38.4159, p=0.0005, OR=4.4, and 95% CI, 2.7%-7.4%). Also, 14.0% of patients and 5.6% of psychiatrists (χ2=4.4950, p=0.003, OR=2.7, and 95% CI, 1.1%-7.5%) considered the use of involuntary treatment of psychiatric patients unacceptable. 
As for the mandatory control of medication intake by patients in a psychiatric hospital by nurses (Table 6), 73.1% of patients and 89.7% of psychiatrists considered it mandatory.


According to 62.6% of psychiatrists and 35.5% of patients, nurses must necessarily control the intake of medications, since patients often do not take, but hide or throw away the dispensed medications (χ2=22.0319, p=0.001 OR=3.1, and 95% CI, 1.8%-5.0%). In addition, 26.9% of patients and 10.3% of psychiatrists (χ2=11.3698, p=0.002, OR=3.2, and 95% CI, 1.6%-6.7%) held opinions about the inappropriateness of drug control.
The use of forced feeding was supported by 87.5% of patients and 96.3% of psychiatrists in cases where the patient refuses to eat with a threat to the life and health of the patient. Forced feeding should be used in any case of refusal to eat, according to 30.8% of psychiatrists and 20.3% of patients (χ2=4.205, p=0.04, OR=1.8, 95% CI, 1.0%-3.0%). Also, 12.5% ​​of patients and 3.7% of psychiatrists pointed out the inadmissibility of force-feeding people with mental disorders in the psychiatric department (χ2=5.6438, p=0.018, OR=3.7, and 95% CI, 1.2%-12.63%).
On average, those with mental disorders preferred to have a somewhat more distant distance from psychiatric patients (3.4±1.9) than with “neighbors down the street” (Table 7).


Psychiatrists chose a more distant one than with “city dwellers” (4.2±1.4). The first distance corresponds to a “geographical distance” of more than 1 km, and the second to more than 10 km. The possibility of close family and friendly relations with people with severe mental disorders was recognized by 40.6% of patients and 11.2% of psychiatrists (χ2=28.956, p=0.001, OR=5.4, and 95% CI, 2.7%-10.9%). Open relationships that allow formal social contact with neighbors and residents of the city suffering from mental disorders were considered possible by 23.2% of patients and 30.9% of psychiatrists.
In addition, 51.4% of psychiatrists and 25.5% of patients (x2=22.256 P=0.0005 OR=3.1 95% CI, 1.9%-5.1%) admit a distanced attitude towards psychiatric patients, the chance of a distanced attitude among psychiatrists is 3 times higher. 10.7% of patients and 6.5% of doctors rejected the desire to contact psychiatric patients - they were accepted only as “tourists in their country” and “would prefer not to see them in their country” (“isolation” and “rejection”).

Discussion
Among the patients, those with severe social disadaptation prevailed, which is confirmed by previous studies of the contingent of patients in a psychiatric hospital [15]: More than half of them had severe mental disorders and disability due to mental disorders. Among non-disabled patients, nearly two-thirds were unemployed. The vast majority of patients completely or partially lacked criticism of their mental health, and they did not understand the essence of their disease due to pronounced self-stigmatization and anosognosia.
Recently, much attention has been paid to the study of psychiatrists’ and patients’ attitudes toward coercion [16, 17, 18], which may be related not only to the therapeutic function but also to the regulatory function of physical restraint. Our study showed that the majority of respondents in both groups considered it justified to force psychiatrists to treat people with mental disorders under any circumstances, which may be due to the dominant paternalistic model in psychiatry. However, the chance of a positive assessment of coercion by psychiatrists was four times higher than by patients. Only a small proportion of respondents in both groups spoke about the inadmissibility of the use of coercion and violence under any circumstances by psychiatrists, which is associated with its negative impact on the therapeutic process [19]. The opinion about coercion to treat people with mental disorders by nurses, among patients and psychiatrists was the same: More than half of the respondents in both groups recognized its admissibility. Moreover, among psychiatrists, the chance of a negative assessment of coercion by nurses was 2.6 times higher than patients, which is also confirmed by our other studies [20].
Psychiatrists had a positive attitude toward the possibility of personally applying physical restraint to an excited patient during voluntary hospitalization, which contradicts the requirements of article 30 of the law of the Russian Federation of 02.07.1992. No. 3185-1 [21]. Psychiatrists were 3.2 times more likely to be encouraged to indulge in physical restraint than patients, which is related to the role psychiatrists are charged with maintaining a safe environment in the psychiatric ward. The patients themselves also confirmed the physician’s use of physical restraint and delegated safety concerns to psychiatrists and indirectly disclaimed responsibility for their actions due to anonymity. Respondents in both groups considered physical restraint to be a function of orderlies, which is confirmed by the results of other studies as a historical practice [22, 23]. At the same time, psychiatrists and patients supported the availability of special restraints in psychiatric hospitals. Psychiatrists were 2.2 times more likely to be encouraged to use physical restraint by nurses without a doctor’s prescription than patients.
Among psychiatrists, the chance of a positive assessment of personal participation in the administration of a sedative injection was 4.2 times more than patients. Most patients endorsed helping other patients to prescribe sedatives to agitated patients, 3.7 times more than psychiatrists. This may be due to the lack of staffing in Russian psychiatric clinics; similar studies were not found.
According to our results, drug coercion ranks second among all types of coercion [24]. Patients were 3.7 times more likely to accept involuntary treatment of people with mental disorders than psychiatrists. Psychiatrists cited public danger as the only reason for involuntary treatment, with a chance more than 4.4 times higher than patients. The odds ratio showed that among patients, a negative assessment of compulsory treatment of persons with mental disorders occurs 2.7 times more often than among psychiatrists.
The majority of patients and psychiatrists approved drug control by nurses in the psychiatric ward, with psychiatrists being 3.1 times more likely to be positively assessed for control. Our results differ from other reports [25], which is due to the paternalistic model dominating Russian psychiatry. Naturally, patients were 3.2 times more likely than psychiatrists to talk about the inappropriateness of medication control, which is associated with a high prevalence of anosognosia among them. The opinions of both groups of respondents about forced feeding when patients in a psychiatric hospital refuse to eat were distributed in a similar manner.
Permissible social distance in relation to mentally ill patients among psychiatrists was significantly more distant than among patients, which is consistent with previous studies [26, 27], confirming the high level of stigmatization of patients by society and psychiatrists. The chance of having friendships and family relationships with this population was 5.4 times higher among the patients than doctors, indicating a lower level of stigma in patients. However, distanced attitudes among psychiatrists were 3.1 times more common than those with mental disorders.

Conclusion
The results showed that psychiatry is dominated by a paternalistic model of the doctor-patient relationship, which is fully supported by both parties. This model places psychiatrists in charge of making decisions concerning the health and lives of patients, as well as public safety and the interests of third parties. At the same time, the distanced attitude of psychiatrists and patients themselves toward people with mental disorders generally reflects the level of stigmatization of psychiatric patients in society and their self-stigmatization. The lack of a clear clinical and legal basis for limiting the rights and freedoms of psychiatric patients, together with the burden of personal responsibility of medical staff and their lack of legal security, leads to abuse, and overt or covert coercion. The high level of anosognosia in patients and a certain ambivalent attitude towards hospitalization and treatment impose not only professional responsibility but also in some cases on the psychiatrist. The leading directions in the prevention of coercion and violence in a psychiatric hospital should increase the competence of the medical staff of psychiatric clinics in the field of medical law, the psycho-education of patients and their relatives, the use of a contract model in the organization of psychiatric care, and the responsibility of patients for their health, behavior, and treatment. 

Ethical Considerations
Compliance with ethical guidelines
The performed procedures in the research involving human participants were in accordance with the ethical standards of the institutional and national study committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study protocol was approved by the Ethics Committee of the Medical Institute of the Belgorod State National Research University and complied with the provisions of the 1995 Helsinki Declaration, as amended and supplemented (Edinburgh, 2000)–protocol No. 12 dated February 6, 2018. Moreover, participating in the study was voluntary, and the study results are available to the study samples upon request.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Conflict of interest
The author declared no conflict of interest.

Acknowledgments
The author acknowledge the patients and medical centers that contributed to this work.


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