The CIN CG system does not provide support for young people who struggle with mental health: The largest number are treated abroad

From 2019 to the end of 2023, the Health Insurance Fund of Montenegro paid more than five million euros for the treatment of 2.216 insured persons with the diagnosis "F" outside of Montenegro, of which more than 97 percent were minors

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Mostly minors are treated outside the country (illustration), Photo: Shutterstock
Mostly minors are treated outside the country (illustration), Photo: Shutterstock
Disclaimer: The translations are mostly done through AI translator and might not be 100% accurate.

The parents of Marko (real name known to the editorial staff) did not understand what was happening. At the beginning of high school, their son, a neat young man and a good student, suddenly changed. Then the first fights at school started, which often led to injuries. That's why they had to change schools.

"We have noticed that he is becoming more and more aggressive and that is why his former friends are avoiding him," his parents told the Center for Investigative Journalism of Montenegro (CIN-CG).

The first attempt to solve this complicated situation was to hire an experienced psychiatrist, who worked in private practice.

"It lasted for more than a year, but without improvement," say the parents with a sigh.

In fact, incident situations continued at school and at home, and thus their son's isolation.

"We tried to offer him small work engagements so that he would not establish social relations. There were no results, on the contrary, another fight took place in the school with serious injuries. We had to change schools again".

After that incident, on the recommendation of another doctor, they decided to turn to a medical institution in Belgrade.

"We rented an apartment and went for daily treatment and consultations. Everything lasted about two months until the definitive therapy was determined".

The Health Insurance Fund pays millions for the treatment of minors outside of Montenegro

The letter "F" in the medical diagnosis indicates a deviation of spirit and consciousness. After the letter comes a combination of numbers that tells in detail what exactly the diagnosis is. There are hundreds of mental illnesses that are classified this way, for example, schizophrenia is labeled as F20 and bipolar affective disorder as F31.

From 2019 to 2023, the number of minors who had to go abroad for treatment doubled. In 2019, 258 of the youngest citizens were treated outside of Montenegro, and in 2023, 568. The number of minor patients increased significantly after the COVID-19 epidemic.

CIN of the CG
photo: CIN CG
photo: cin

The amount needed for that treatment has also doubled. In 2019, the Fund paid the amount of 606.916 euros, and in 2023, 294 euros.

For the years 2022 and 2023 alone, the Fund records spending of over two and a half million euros for the treatment of 1.100 minors and 24 adult citizens with the diagnosis "F" outside of Montenegro.

Minors have been staying illegally in Dobrota for years

When the family from the beginning of the story returned to Montenegro, the situation did not change for the better. In fact, their son's aggressiveness also manifested itself towards those closest to him. During that period, a dramatic incident took place - an attempt at self-harm. After the reaction of the emergency services, the young man was hospitalized in the Special Hospital for Psychiatry "Dobrota" (SB Dobrota). This hospital then, as well as now, was not authorized to receive minors for psychiatric hospital treatment. However, the parents had no other choice.

In 2023, five minors were hospitalized in SP Dobrota, and by September 2024, four more were admitted.

"There is constant pressure to admit minors. We refuse everything we can refuse, even though the pressures are increasing", says the director of SP Dobrota in an interview for CIN-CG. Aleksandar Macic.

However, in Montenegro it is illegal to treat minor patients in the same departments where adults are treated. According to Article 54 of the Law on the Protection and Exercise of the Rights of Mentally Ill Persons, a fine of 1.000 to 20.000 euros is provided for a psychiatric institution that does not treat mentally ill minors separately from adult patients.

SB Dobrota is the only specialized hospital for psychiatry in Montenegro.

"Given the overcrowding of SB Dobrot, we have a serious problem of providing the minimum legal conditions for the stay of minor patients. That's why we accepted only those who seriously endanger themselves or others due to illness, with the mandatory consent of their parents," explains Mačić.

Despite this, there was a tendency to refer the youngest to hospital treatment in SB Dobrota, either by judicial authorities or by emergency services and family, because there was no alternative.

"This creates a paradox, for example, if a judge issues a decision to refer a minor to Dobrota, and by law that health institution cannot provide assistance to minors. Despite such an undefined situation, this medical institution still tries to provide the necessary help", he told CIN-CG Sanja Šisović, program director of the civil sector organization CAZAS, which provides psychosocial assistance to young people and vulnerable groups in Montenegro.

Support for children's mental health had to exist in schools as well: Sanja Šišović
Support for children's mental health had to exist in schools as well: Sanja Šišovićphoto: Private archive

In two cases, the patients were referred by the court, in the others it was the recommendation of a child psychiatrist from Podgorica.

"Hospitalizations are always short. We are trying to shorten the duration of hospitalization, until hospitalization is provided in other specialized institutions outside Montenegro", says Mačić.

According to his opinion, after the opening of the new Dobrota clinic, it will no longer accept minor patients.

"In any case, we will no longer accept minors, regardless of their clinical picture," Mačić said.

The new psychiatry clinic has conditions for hospital treatment of minors

Hospital treatment of minor psychiatric patients was not possible in Montenegro until a few days ago.

For 15 years, there were no conditions for hospital treatment of minors with mental difficulties in any institution. The youngest patients who needed psychiatric health care had to go for treatment abroad or illegally to SB Dobrota.

Department of Child and Adolescent Psychiatry
Department of Child and Adolescent Psychiatryphoto: CIN CG

The Department for Juveniles will be located in the new Psychiatry Clinic within the Clinical Center of Montenegro (KCCG) in Podgorica, which was officially opened on September 18.

"Instead of the previous seven rooms and 40 beds, in the new facility we will have 20 rooms with 57 patient beds," said the director of the KCCG. Aleksandar Radovic.

Are 12 beds enough?

The department for child and adolescent psychiatry will have 12 beds divided into four rooms.

It is not known how many minors have psychiatric illnesses and mental problems in Montenegro. Although it was foreseen in the Strategy for the Protection and Improvement of Mental Health in Montenegro 2019-2023 (Strategy), no research has been done to date on the state of mental health of the population, including the impact of the COVID-19 epidemic. The new strategy has not yet been adopted.

Although it is very difficult to get a concrete number, CAZAS estimated that in 2023, around 10.000 families faced a mental health diagnosis. These are estimates based on the number of people who requested help in the public health sector. According to their data, a large number of patients suffer from addiction, depression and bipolar disorder.

The department for child and adolescent psychiatry will be open. Director SB Dobrota told CIN-CG that, based on his experience, he believes that it is necessary for the department to be closed. Psychiatric treatment of all persons, especially minors, is an extremely complex, multidisciplinary process that requires adequate conditions with educated staff at all levels, the doctor of child psychiatry points out in an interview for CIN-CG Iva Ivanovic from the Center for Autism, Developmental Disabilities and Child Psychiatry.

"Hospital treatment requires, first of all, the provision of patient safety and security, as well as adequate treatment," says Ivanović.

The system of early recognition is insufficient

The challenges that Montenegro is currently facing are the lack of staff and space, but also the lack of continuous education at all levels, Ivanović explains.

"Unlike other branches of medicine, which require large investments and instruments, devices, psychiatry requires the most investment in educating people and creating pleasant conditions for patients to stay".

The presence of psychologists and pedagogues in schools does not currently represent a great source of prevention and support in the field of mental health of children and teenagers, according to Ivanović.

"These roles in schools need to be strengthened," she claims.

Mental health centers at health centers have also made a positive step forward, explains Šišović.

CIN of the CG
photo: CIN CG
CIN of the CG
photo: CIN CG

"Those centers have psychiatrists and psychologists and thus shortened the path to a mental health specialist at the primary level. However, challenges remain. "Mental health centers have limited capacities, they are not available in all health centers and have a limited number of appointments", says Director of CAZAS Šišović.

There are eight units for mental health within the health centers, while the health centers in Budva, Danilovgrad, Herceg Novi, Mojkovac and Plav only have these units on paper because they do not meet the personnel standards, according to the Strategy.

Šišović explains that support for children's mental health should also exist in schools.

"While we are witnessing an increase in episodes of social manifestations such as: peer violence, violence in general, cyber bullying, all schools do not have pedagogical-psychological services," she says.

Suicides

In five years, from 2017 to 2022, 17 minors took their own lives in Montenegro, the Police Administration announced for CIN-CG.

In the course of 2022 and 2023, 189 people tried to commit suicide, while in the first half of 2024 there were 43 such attempts. Health institutions do not keep a register of suicide attempts, although, according to well-informed sources of CIN-CG, there was an urgency from the Institute for Public Butchery to create this register. CIN-CG addressed the Ministry of Health with questions about the register of suicide attempts, but did not receive an answer until the publication of this text.

"Montenegro still does not have an established SOS line for suicides, and the youngest person who asked for support due to suicidal thoughts was 16 years old," a specialist in clinical psychology and founder of the non-governmental organization Center for Suicide Prevention tells CIN-CG Nebojsa Žižić.

In Europe, suicide is the second most common cause of death among adolescents aged 15 to 19, after traffic accidents. Every year, almost 1.200 adolescents in Europe take their own lives. That's almost three lives a day, according to UNICEF's analysis: "The State of Children in the World 2021".

The report also shows that nearly nine million adolescents are living with a mental health disorder, with anxiety and depression accounting for more than half of all cases.

Increase in the number of psychiatric examinations after COVID-19

"The opening of the Center for Autism, Developmental Disabilities and Child Psychiatry in the spring of 2018, as well as the arrival of the first specialists in child and adolescent psychiatry, enabled our youngest citizens to receive help in their own country when it comes to mental health challenges and problems," says the doctor. Ivanovic.

Children can have a medical examination by going directly to the Center or through a selected pediatrician, she explains.

The Center says that there has been a significant increase in the number of examinations in the field of child and adolescent psychiatry after the pandemic. "There are almost one hundred percent more views, if we compare the figures from 2019 and 2023. During 2023, we had about 3.000 visits to child and adolescent psychiatrists," Ivanović points out.

As he explains, at the moment they cannot announce the exact number of patients visiting the Center for Early Development, but according to some estimates, that number is around eight thousand. This includes those who are only looking for the services of speech therapists, psychologists or defectologists.

The most vulnerable groups are children and adolescents who had mental health problems even before the COVID-19 pandemic, however, says this psychiatrist, there are also minors who experienced their first problems during or after the pandemic.

"These experiences teach us that in some future, similar, challenging situations, we must pay special attention to the mental health, especially of the most vulnerable groups, children and adolescents in development," she points out.

On the other hand, Šišović says that the pandemic has also brought some good things.

"Now it is more socially acceptable to admit that one experiences difficulties with mental health, although the road to destigmatization is still long. Young people are often ashamed and hide mental difficulties. "Many parents certainly have a diagnosis, but since they have never seen a professional in their life, they don't know," says Šišović.

Why young people seek help

The Center for Autism, Developmental Disabilities and Child Psychiatry tells CIN-CG that young people between the ages of 11 and 18 most often turn to the problem of adolescent crisis, i.e. adjustment disorder.

"Considering that adolescence represents the second most important point of postnatal development, we should not be surprised why this period can be very challenging for the mental health of young people," say the Center.

"In addition to hormonal changes, there are significant biological and neurological changes, in this period we also detect behavioral and emotional disorders. At a later age, authentic depressive episodes. Also, disorders from the psychotic spectrum occur, whether as a psychotic reaction to a stressful situation or as the beginning of a longer-term psychotic process," explains psychiatrist Ivanović.

Worldwide research shows that poor social status negatively affects mental health, including the mental health of adolescents and families. It is also warned of the ever-increasing demands of the modern age and way of life. Ivanović also lists the excessive use of mobile phones and computers, life in the virtual world, abuse of psychoactive substances, stigmatization of diversity, trauma, an environment that promotes only the material aspect of human beings as a group of risks...

"However, taught by practical experience, we cannot leave out the family as perhaps the most important and significant value for the mental health of children and adolescents," explains Ivanović.

A good family (caring, close, with strong emotional ties) represents a good prognostic sign, if there are challenges in the mental health of adolescents. However, a family that does not successfully cope with challenges, along with an inadequate role of parents, entails a worse impact on the mental health of adolescents. Not so rarely, bad family dynamics can be the basis for the emergence of difficulties in the mental functioning of children and adolescents.

Self-harm is a warning sign

Ivanovic explains to CIN-CG that self-harm is more often actually a sign of a call for help than of taking a life. "There is non-suicidal self-injury - we can consider it a symptom that we often encounter among adolescents who seek our help," says Ivanovic.

She explains that it is about injuring one's own body (also soul) due to the inability to deal with problems, difficulties in one's own functioning, the reasons for which can be multiple. It occurs in fragile, insufficiently mature personalities, with weak defense mechanisms, which contribute to affective instability and impulsive reactions.

"Nevertheless, frequent self-harm contributes to a higher risk of suicide."

She explained that there were also suicide attempts caused by impulsive reactions, but sometimes they arose as a process of prolonged thinking and suicidal ideation.

"Among the reasons, problems of not adapting to family and social situations are mostly present, although according to global research, the reasons can also be biological, such as endogenous depression or other psychopathological processes," says Ivanović.

"These are patients who require immediate hospital treatment, and so far they have been referred for hospital treatment abroad, most often to psychiatric clinics in Belgrade," she explains.

The director of the NGO CAZAS warns about the effects of sending children abroad for treatment.

"The state does not know what is happening with them, and thus minors remain under the radar. This means that we don't have health statistics and we lose track of them," says Šišović.

A call to action

"Society should be more open to diversity. We need solidarity and compassion, a hand of help and understanding, and less pity, labeling and rejection", says Ivanović.

She believes that through the creation of smart and caring policies for the development of children and youth, the state should create, strengthen and encourage the pillars of society that are most important for the stable development of society - good health care, education, social support, but also culture in the broadest sense of the word. He points out that it is important that young people are aware at all times that help is available and that no one is alone.

Today, Marko is an adult, he lives with therapy with a psychiatric diagnosis, he does not have a job, and he can only count on his parents.

CIN of the CG
photo: CIN CG

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